VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Discovery Village at the West End
2422 University Park Boulevard
Richmond, VA 23233
(804) 554-1555

Current Inspector: Shelby Haskins (804) 305-4876

Inspection Date: Nov. 10, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

A non-mandated self-report inspection was initiated on October 26, 2021 and concluded on November 16, 2021. A self-reported incident was received by the department regarding allegations in the areas of resident care and related services. The Senior Executive Director was contacted to conduct the investigation. The licensing inspector emailed the Senior Executive Director a list of documentation required to complete the investigation. The licensing inspector conducted an on-site observation at the facility on November 10, 2021. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and violations were issued. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-640-A
Description:	Based on record review and interview with staff, the facility failed to ensure methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. Evidence: 1. The facility?s ?Controlled Substances Accountability? policy documents, ?At the beginning and end of every shift the receiving/oncoming nurse/medication technician will count all controlled substances currently being stored by the community in the locked narcotic boxes. This count will take place in the presence of the off going nurse/medication technician.? Additionally, it documents, ?Controlled medications will be counted by both staff and signed off on the Narcotic Count Sheet.? 2. According to the ?Controlled Drug Counts Record?, the following shifts were missing a sign-off of the controlled medications: a. 10-01-2021: 11 p.m. ? 7 a.m. on and 11 p.m. ? 7 a.m. off; b. 10-02-2021: 11 p.m. ? 7 a.m. off; c. 10-03-2021: 3 p.m. ? 11 p.m. on and 3 p.m. ? 11 p.m. off; d. 10-11-2021: 11 p.m. ? 7 a.m. off; e. 10-16-2021 3 p.m. ? 11 p.m. off; f. 10-17-2021 7 a.m. ? 3 p.m. on and 7 a.m. ? 3 p.m. off; and g. 10-21-2021 3 p.m. ? 11 p.m. on and 3 p.m. ? 11 p.m. off. 3. Staff #1 confirmed during interview the aforementioned dates and times were not signed off to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes.
Plan of Correction:	Weekly narcotic count audits will be conducted by the ED and DHW. All Medication Aides will be re-educated on the important of counting the narcotic medications and initialing off on the narcotic count sheets.
Standard #:	22VAC40-73-680-B
Description:	Based on record review and interview with staff, the facility failed to ensure medications remained in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident. Evidence: 1. The following was reported by the facility on 10-26-2021: ??we have had two instances of missing narcotics from our Assisted Living medication cart?The first instance was on Sunday, October 17th?During the count, the Med Tech that came in at 4 noticed that a card of Oxycodone was missing for [Resident #1]. The resident has two cards of the narcotic, one for AM and one for PM. The second instance was on Saturday, October 23rd? one of our Med-Techs, reported that [Resident #2] also had one card of Oxycodone that was missing from the cart. [Resident #2] used two cards of the narcotic, one for AM and one for PM? In both instances, both the medication and the narcotic count sheet were taken...? 2. Staff #2?s statement confirmed Resident #1?s missing Oxycodone on 10-16-2021 11 p.m. shift into 10-17-2021 with further investigation by Staff #2 and Staff #3 and learned the narcotic count sheet was also missing for Resident #1?s narcotic medication. 3. Staff #4?s statement confirmed Resident #2?s missing Oxycodone on 10-23-2021 night shift (3 p.m. - 11 p.m.) as well as the narcotic count sheet was also missing for Resident #2?s narcotic medication. 4. Staff #1 confirmed Resident #1 and Resident #2?s medications did not remain in the pharmacy issued container until administered to the resident for both residents? Oxycodone prescription medications.
Plan of Correction:	The Facility implemented a new process in which the number of narcotics will be counted twice each shift in addition to the normal count at each shift-change. The ED and DHW will do weekly audits to ensure this process is being followed.