VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Carriage Hill Retirement
1203 Roundtree Drive
Bedford, VA 24523
(540) 586-5982

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: Oct. 12, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical Assistance:

To ensure that the facility had a thorough understanding of standards, the licensing inspector and the Administrator had a discussion regarding standard 680-D.

Comments:

A non-mandated monitoring inspection regarding an intensive plan of correction (IPOC) was initiated on 10/12/2021 and concluded on 10/13/2021. The licensing inspector conducted an on-site observation at the facility on 10/12/2021 and the Administrator emailed the licensing inspector items requested by the licensing inspector to conduct the follow-up on 10/12/2021. There were no repeat violations from the non-mandated monitoring inspection regarding the IPOC; however, any violations not related to the non-mandated monitoring inspection but identified during the course of the inspection can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-640-A
Description:	Based on observation and document review, the facility failed to implement their medication management plan regarding methods to ensure accurate counts of all controlled substances. EVIDENCE: 1. The facility?s current medication management plan states that ?Each controlled substance will be tracked using a separate Controlled Medication Log which meets the requirements of state and federal narcotic enforcement agencies. At the end of each shift, the outgoing and incoming RN, LPN, or RMA authorized to administer medications, will count all controlled substances and sign the Controlled Medication Log verifying the count is accurate.? 2. The record for resident 1 contains a physician?s order, dated 05/05/2021, for ?morphine concentrate 100 mg/5mL (20 mg/mL) oral solution take ? ml by mouth every three hours as needed for pain?. 3. At approximately 10:29AM during on-site inspection on 10/12/2021, the most recent log entry, dated 08/17/2021, on the ?Controlled Drug Record? indicated that there were 26.75 mL of morphine; however, the bottle of morphine for resident 1 showed that there were 24 mL of morphine. Staff 1, 2 and 3 confirmed that the bottle contained 24 mL of morphine.
Plan of Correction:	The bottle of morphine was removed from the cart and sent to the pharmacy. Pharmacy confirmed morphine bottle leaked. To prevent the potential of this occurring again, moving forward, facility will distribute morphine in prefilled syringes. Facility will not accept a morphine bottle without a bung or stopper. Prefilled syringe and a bottle stopper will prevent leaking.