VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Birch Gardens
12 Royal Drive
Staunton, VA 24401
(540) 886-5007

Current Inspector: Jessica Gale (540) 571-0358

Inspection Date: Nov. 16, 2021 , Nov. 17, 2021 , Nov. 19, 2021 and Dec. 8, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical Assistance:

Ensure all staff receive on-going training on the standards and facility policies regarding resident emergencies and reporting major incidents to the licensing office.

Comments:

A non-mandated complaint inspection was initiated on 11/16/2021 and concluded on 12/8/2021. A complaint was received on 11/16/2021 by the department regarding allegations in the areas of administration and administrative services and resident care and related services. The administrator was contacted by telephone regarding the documentation required to complete the investigation. In addition, telephone interviews were conducted. The evidence gathered during the investigation did not support the allegation of non-compliance with staff not obtaining medical care for a resident; however, it did support the allegation of a family member not being notified of an incident. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-70-A
Complaint related:	No
Description:	Based upon documentation and an interview, the facility failed to ensure five major incidents that negatively affected the life, health and safety or welfare of a resident were reported to the licensing office within 24 hours. Evidence: 1. A facility incident report form was completed on 9/9/2021 for resident 1 stating, "Staff went to answer call bell found res. on the floor. Res. had a cut above her left eye and was bleeding. Hospice was called, 911 called sent to ER." 2. On 11/19/2021, the licensing inspector (LI) interviewed the administrator who stated this incident was not reported to the licensing office and was an oversight. 3. On 11/19/2021, the administrator sent an electronic message also stating the incident on 9/9/2021 was not reported to the licensing office. 4. On 11/23/2021, the administrator first notified licensing of incidents where residents were sent to the emergency room on 11/19/2021 (resident 2 and 3), 11/20/2021 (resident 4) and 11/21/2021 (resident 5).
Plan of Correction:	Administrator and director of nursing (DON) were re-in-serviced on reporting to the regional licensing office within 24 hours any major incident that has negatively affected or threatens the life, health, safety, or welfare of any resident. The administrator and DON will review submitted incident reports daily to ensure compliance with timely submission of incident reports for continued compliance.
Standard #:	22VAC40-73-460-F
Complaint related:	Yes
Description:	Based upon documentation and an interview, the facility failed to ensure all required individuals were contacted when a resident fell. Evidence: 1. A facility incident report form was completed on 9/9/2021 for resident 1 stating, "Staff went to answer call bell found res. on the floor. Res. had a cut above her left eye and was bleeding. Hospice was called, 911 called sent to ER." 2. The family notification section on the form only listed hospice as being notified. 3. On 12/8/2021, the LI interviewed the administrator who stated there was no documentation that the family was notified of the incident.
Plan of Correction:	Administrator and DON will retrain all staff to ensure they contact the family or designated contact person any time a resident incident occurs. The DON will document all incidents as required and ensure all required parties are notified of the incidents. The DON will ensure all notes and notification information is documented in the resident's record to include the date, time, caller and designated contact person who was notified. The administrator will check and sign off on all reports to ensure compliance.