VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brookdale Staunton
1900 Hillsmere Lane
Staunton, VA 24401
(540) 885-9500

Current Inspector: Jessica Gale (540) 571-0358

Inspection Date: Nov. 22, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

A non-mandated self-report inspection was initiated on 11/22/2021 and concluded on 11/24/2021. A self-reported incident was received by the department regarding allegations in the areas of resident care. The Health and Wellness Director was contacted by telephone to conduct the investigation. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and a violation was issued.

Violations:

Standard #:	22VAC40-73-680-D
Description:	Based upon documentation and an interview, the facility failed to ensure one of two residents' medications were administered as ordered by the physician and in accordance with the standards of practice as outlined in the current medication aide curriculum. EVIDENCE: 1. A major incident report submitted on 11/22/2021 stated on 11/21/2021 at 9:00 pm, staff 1 administered resident 1 the scheduled 10:00pm medications Gabapentin 100; Janumet XR 50-1000mg; Protonix 40mg; Carvedilol 3.125mg; Trazadone 100mg and Duloxetine HCL 50mg, which were for resident 2. 2. The November Medication Administration Record (MAR) for resident 1 listed the 8:00pm medications as Lipitor 80mg and Melatonin 8mg. 3. The November Medication Administration Record for resident 2 listed the 10:00pm medication as Gabapentin 100mg; Janumet XR 50-1000mg; Protonix 40mg; Carvedilol 3.125mg; Trazadone 100mg and Duloxetine HCL 50mg. 4. The LI interviewed staff 2 on 11/21/2021 who stated staff 1 went into the wrong room and didn't verify the resident's name prior to administering the medication. 5. Section 4.2.A.4 of the current medication aide curriculum states, "Get the medication container from the cart/cabinet and read the label to verify the: right client, right drug, right dose, right route, right time."
Plan of Correction:	1). Residents MD was notified, POA notified regarding medication administration error. LPN staff #1 no longer works at facility. 2). Current registered and licensed staff will be reeducated on the 7 rights of medication administration by the Health and Wellness Director no later than 12/16/21 3). An medication administration observation will be conducted by the Health and Wellness Director/ designee of current registered and licensed nursing staff to verify the 7 rights of medication administration are being observed no later than 12/16/21 . 4). On a monthly basis for 6 months the Health and Wellness Director / Designee will observe monthly medication administration observations of registered and licensed staff to verify the 7 rights of medication administration are being observed.