VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Tribute at One Loudoun, LLC
20335 Savin Hill Drive
Ashburn, VA 20147
(571) 252-8292

Current Inspector: Laura Lunceford (540) 219-9264

Inspection Date: Oct. 4, 2021 and Dec. 13, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

A non-mandated complaint inspection was initiated on 10/04/2021 and concluded on 12/13/2021. A complaint was received by the department regarding allegations in the areas of resident care. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation support the allegations of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice. Please specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation and if you have any questions please call 703-479-5247 or contact me via e-mail at jamie.eddy@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-460-A
Complaint related:	No
Description:	Based upon a review of records, the facility failed to ensure the health, safety, and well-being of the resident by failing to follow fall response procedures developed by the facility. Evidence: 1. According to the facility?s Fall Response Procedures dated 6/8/2021, a resident who has sustained a fall can be assisted up to a chair if the head did not receive any trauma or injury, nor was struck during the fall. Progress notes for 9/10/2021 report that Resident #1?s head was struck when he fell and that Staff #1 observed a red mark on the right temple area. Interview with Adult Protective Services Worker revealed that Resident #1 was returned to his bed despite having had struck his head. 2. According to the facility?s Fall Response Procedures dated 6/8/2021, a resident who has sustained a fall can be assisted up to a chair if the resident denies pain. The progress notes indicate that Resident #1?s pain level was an 8 out of 10 and Resident #1 reported ?increased right leg pain.? Interview with Adult Protective Services Worker revealed that Resident #1 was returned to his bed despite having had reported increased right leg pain. 3. According to the facility?s Fall Response Procedures dated 6/8/2021, ?if a resident had trauma resulting in deformity, exhibits any change in level of consciousness, or received obvious head or significant trauma, the Resident Services Director or Care Partners will summon Emergency Medical Services (call 911).? Interview with Staff #1 confirmed that 911 was not called for Resident #1, who had hit his head and reported increased pain in his right leg. Resident #1 was taken to the ER after Collateral Contact #1 received a text message from Resident #1 indicating that he had suffered a fall and Collateral Contact #1 contacted 911 at approximately 5:40 pm on 9/10/2021.
Plan of Correction:	1. It is duly noted that the facility nurse did not follow the facility's fall response procedures; the nurse is no longer employed by the facility. 2. The Resident Services Director, or designee, will re-educate nurses, medication care partners, and care partners on the facility's fall response procedures.
Standard #:	22VAC40-73-550-C
Complaint related:	No
Description:	Based upon a review of records and interviews, the facility failed to ensure that any resident of an assisted living facility has the rights and responsibilities as provided in ? 63.2-1808 of the Code of Virginia and this chapter. According to ?63.2-1808 of the Code of Virginia-Rights and Responsibilities of residents of assisted living facilities: A-6 In the event a medical condition should arise while he is residing in the facility, is afforded the opportunity to participate in the planning of his program of care and medication treatment at the facility and the right to refuse treatment. Evidence: 1. According to the progress notes entered at approximately 1:27 pm on 9/10/2021, Resident #1 sustained a fall from standing and hit his head on the right side. Staff #1 assessed the Resident and observed ?some redness on Rt temple.? The progress notes indicate that the Resident did not lose consciousness and was alert and oriented times three. The progress notes reported that the Resident had normal range of motion of left upper and lower extremities and that ?Rt sided weakness and limited ROM of RUE and RLE is baseline for resident.? According to the progress notes, ?Resident reports increased Rt leg pain and requests medications.? The documented pain level was 8 out of 10 for the resident. The resident requested and was administered pain medications and placed back into bed. 1. According to the interview with Staff #1 from 11/1/2021, when being assessed for possible injuries from the fall on 9/10/2021, Resident #1 had ?difficulty communicating whether the pain he was experiencing was new or old pain and would not answer questions being asked of him.? Staff #1 commented that Resident #1 ?does not communicate well when he is in pain.? Staff #1 stated she did observe a pink mark on the right temple area of the Resident #1. According to Staff #1, there had been a previous incident in which Resident #1 was in pain and requested to be sent out to the hospital. Staff #1 was asked if Resident #1 was offered the option of going to the hospital or did Resident #1 communicate that he did not want to go to the hospital. Staff #1 responded ?he did not ask to go to ER and I did not offer.? Staff #1 commented that based upon her assessment of Resident #1 it was determined that Resident #1 did not need to be sent out to the hospital. 2. According to an interview with Collateral Contact #1 on 10/28/2021, Staff #1 left a voicemail message at approximately 1:17 pm on 9/10/2021, asking for a return call in regards to Resident #1, but the voicemail message did not mention that Resident #1 had fallen. At approximately 5:40 pm, Collateral Contact #1 received a text message from Resident #1 that stated ?Do I fall bad.? The Collateral Contact contacted 911 and requested that Resident #1 be sent out to the hospital for evaluation. According to Collateral Contact #1, on 9/10/2021, Resident #1 was diagnosed with a fractured right hip and had surgery within 12 hours of the diagnosis. Resident #1 also suffered a fractured right elbow. Collateral Contact #1, reported that surgery for the fractured elbow was not going to be performed.
Plan of Correction:	1. It is duly noted that the facility nurse did not ensure the resident's rights and responsibilities as provided in ?63.2-1808 of the Code of Virginia.; the nurse is no longer employed by the facility. 2. The Resident Services Director, or designee, will re-educate nurses, medication care partners, and direct care partners on the resident's rights and responsibilities as provided in ?63.2-1808.