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Shenandoah Place, Inc.
50 Burkholder Lane
New market, VA 22844
(540) 740-4300

Current Inspector: Laura Lunceford (540) 219-9264

Inspection Date: Nov. 3, 2021

Complaint Related: No

Areas Reviewed:
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES
22VAC40-73 PERSONNEL
22VAC40-73 STAFFING AND SUPERVISION
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
22VAC40-73 EMERGENCY PREPAREDNESS

Comments:
An unannounced monitoring inspection was conducted. The focus of the inspection was to determine whether the provider had corrected or is in the process o correcting previously cited violations within the area of the standards referenced above. Any non-compliant elements of law or regulations are documented in the Violation Notice of this inspection.

Violations:
Standard #: 22VAC40-73-680-D
Description: Based on a review of residents' records, the facility failed to ensure medications are administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.
EVIDENCE:
1. Page 181 of the current registered medication aide curriculum approved by the Virginia Board of Nursing indicates "medication aides may not assess for medical need nor the assessment of the medical need be delegated to an unlicensed person by a registered nurse of a physician."
2. Resident 1 has the following order: Buspirone 5mg tablet-Take one tablet by mouth two times daily as needed for anxiety disorder.
3. The October Medication Administration Record (MAR) for resident 1 indicates medication was administered on 10/18/2021 at 5:22am "given to patient for agitation before Activities Daily Living (ADLs) are performed"
4. Documentation on Medication Administration Record (MAR) for resident 1 indicates medication was administered on 10/19/2021 at 5:25am "for staff to be able to give ADLs safely"
5. Documentation on Medication Administration Record (MAR) for resident 1 indicates medication was administered on 10/19/2021 at 5:32pm "resident seems agitated and anxious"
6. Documentation on Medication Administration Record (MAR) for resident 1 indicates medication was administered on 10/20/2021 at 2:33pm "agitation"
7. Documentation on Medication Administration Record (MAR) for resident 1 indicates medication was administered on 10/23/2021 at 5:19am "to help with aggressive behavior during ADLs"
8. Documentation on Medication Administration Record (MAR) for resident 1 indicates medication was administered on 10/26/2021 at 6:08am "to control violent outbursts during ADLs"
9. Documentation on Medication Administration Record (MAR) for resident 1 indicates medication was administered on 10/27/2021 at 5:41am "to control violent outbursts towards staff during ADLs"
10. Documentation on Medication Administration Record (MAR) for resident 1 indicates medication was administered on 10/27/2021 at 3:54pm "Resident seems very anxious trying to get out of chair"
11. Documentation on Medication Administration Record (MAR) for resident 1 indicates medication was administered on 10/29/2021 at 2:33pm "to control violent outbursts during ADLs"
12. Documentation on Medication Administration Record (MAR) for resident 1 indicates medication was administered on 10/29/2021 at 6:25pm "resident is combative"
13. Documentation on Medication Administration Record (MAR) for resident 1 indicates medication was administered on 10/31/2021 at 5:46am "to control violent outbursts during ADLs"
14. Documentation on Medication Administration Record (MAR) for resident 1 indicates staff 1, 2 3 and 4 who administered the medication, are registered medication aides.

Plan of Correction: All Registered Medication Aides (RMAs) are in the process of re-training specifically regarding documentation in PRN administration circumstances and recertification of medication aide training (yearly).
Ongoing training occurs with RMA staff related to resident redirection, de-escalation technique to utilize if resident appears combative or displays hitting actions to ensure that resident care is managed in a safe and appropriate manner.

Standard #: 22VAC40-73-680-K
Description: Based on review of residents' records, the facility failed to ensure PRN medication orders contain all required conditions when medication aides administer the PRN medication.
EVIDENCE:
1. The Medication Administration Record (MAR) for resident 1 shows medication aides administered PRN medication for the month of October.
2. Resident 1 has the following order: Buspirone 5mg tablet-Take one tablet by mouth two times daily as needed for anxiety disorder.
3. The physician's order does not include symptoms that indicate the use of the medication and the exact time frames the medication is to be given in a 24 hour period.

Plan of Correction: In process of obtaining written order from resident's physician. The order shall include symptoms that indicate the use of the medication, the exact dosage, the exact time frames the medication is to be given in a 24 hour period, and directions as to what to do if symptoms persist. The nurse manager will oversee all future PRN orders to evaluate whether they follow stated regulation.

Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.

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