VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Carriage Hill Retirement
1203 Roundtree Drive
Bedford, VA 24523
(540) 586-5982

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: Dec. 13, 2021 and Jan. 31, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

The licensing inspector (LI) for Carriage Hill Retirement initiated an unannounced focused monitoring inspection via phone on 12/13/2021 and an on-site inspection on 01/31/2022 in conjunction with another LI to follow-up on a facility reported incident of an elopement of a resident who resides in the facility's safe, secure unit that occurred on 12/06/2021. Findings were reviewed with facility staff during the on-site portion of the inspection on 01/31/2022. An exit interview was conducted with the Administrator on 02/09/2022, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it to your licensing inspector within 10 calendar days from today. If you have any questions, contact your licensing inspector at (540) 589-5216.

Violations:

Standard #:	22VAC40-73-450-C
Description:	Based on resident record review and staff interview, the facility failed to ensure residents? individualized service plans (ISP) included all required components. EVIDENCE: 1. Resident 1 was admitted to the facility?s safe, secure unit on 11/18/2021. 2. The record for resident 1 contains the document ?Regional Discharge Assistance Program Provider Agreement? (DAP Agreement), signed by staff 1 on 11/25/2021, that indicates the following information: ?Due to (resident?s) overt opposition both verbally and non-verbally (elopement) and aggressive behaviors surrounding his ability to do so (Verbally aggressive with yelling, slapping tables, and modeling delusions with reenactments) (resident) is approved for Tier 1 supports at Carriage Hill Retirement. These supports include additional resident assistance surrounding time related to escorting, reminders, and overall staff support, as needed. Tier 1 supports also provides support around activities of daily living that will help create meaningful daily activities, which will help provide coping strategies for his depression. Although (resident) can perform his ADL?s he needs supervision and prompts in order to do so. Tier 1 level of care provides these supports in order for him to maintain consistency and ensure cleanliness for overall general health.? and ?Because (resident) experiences baseline delusional and paranoid thinking, especially surrounding his family, it is important to redirect him to preferred topics in an effort [sic] avoid escalation. These baseline behaviors consist of `suing? his family and homicidal statements and ideation surrounding them. (Resident) enjoys talking about hunting and reading hunting magazines. He also enjoys trout fishing and can be verbally redirected with this topic. If escalation should occur, the DAP Specialist (name below) should be contacted immediately, as well as any Horizon CSB Case Management Services (if applicable).? The aforementioned information was not included on the resident?s comprehensive ISP dated 11/17/2021. 3. The public pay uniform assessment instrument (UAI), dated 10/13/2021, for the resident showed the following information: ?Prior to admission (resident) was discharge [sic] to an AFL (assisted living facility) where he eloped from to go drinking with a friend? and ?Family and AR reported that patient stays Drunk. Patient eloped from ALF to go Drinking with friends and refused to return?. This information was not included on the resident?s individualized service plan (ISP) dated 11/17/2021.
Plan of Correction:	The DAP Agreement listed in the evidence is not a medical tool that is required to be used in developing an Individualized Service Plan as it is essentially a financial agreement between a government agency and our property for purposes of designated how an individual will be paying the community for its services. As this is not a legitimate medical document, we do not use this for historical documentation purposes for translating information to our ISP?s and UAIs. We use H&P?s hospital notes, social assessments, and other clinical documents to formulate these important documents. As it relates to Evidence number 2, we have updated the ISP to reflect the consistent information noted in the UAI so that both documents match and are reflective of the same information.
Standard #:	22VAC40-73-460-D
Description:	Based on resident record review and staff interview, the facility failed to ensure supervision of resident schedules, care, and activities, including attention to specialized needs, such as wandering from the premises. EVIDENCE: 1. The ?Report of Resident Physical Examination? for resident 1, dated 11/05/2021, showed that the resident is ?nonambulatory (by reason of physical or mental impairment is not capable of self-preservation without the assistance of another person).? and the ?Assessment of Serious Cognitive Impairment? for the resident, dated 11/05/2021, showed that the resident has a serious cognitive impairment due to a primary psychiatric diagnosis of dementia and is unable to recognize danger or protect his/her own safety and welfare.? 2. The public pay uniform assessment instrument (UAI), dated 10/13/2021, for the resident showed the following information: ?Prior to admission (resident) was discharge [sic] to an AFL (assisted living facility) where he eloped from to go drinking with a friend? and ?Family and AR reported that patient stays Drunk. Patient eloped from ALF to go Drinking with friends and refused to return?. This individualized service plan (ISP) for resident 1, dated 11/17/2021, does not address the identified information from the UAI that the resident left the previous assisted living facility he resided at. 3. Resident 1 was admitted to the facility?s safe, secure unit on 11/18/2021. 4. Incident report from staff 1 emailed to the licensing inspector (LI) on 12/07/2021, stated that on ?12/06/21, between 8 and 9am? the following occurred: ?Resident was present during night shift morning round. During Day shift morning round staff noticed resident had left his room through the window. Administrator was notified and the facility staff started looking for resident. After a thorough search of both buildings, the administrator called the police. Administrator continued search until he found resident around 10am. The administrator found resident at Huddleshouse [sic] in front of Walmart. Administrator stayed with resident until police officer arrived and resident was taken back to the facility.? Google maps shows that it is at least a 4.2 mile walking distance from the facility to the Huddle House, located at 1138 E Lynchburg Turnpike Bedford, Virginia 24523, where the resident was found by the administrator. 5. According to timeanddate.com, the temperature for 12/06/2021 from 7:54 AM to 10:54 AM was between 50 degrees Fahrenheit and 65 degrees Fahrenheit.
Plan of Correction:	In our memory care, and as reflected in our rental agreement, Carriage Hill Retirement does not provide one on one care to our residents. Carriage Hill was in compliance with routine evening, night shift, and morning shift rounds on residents, including resident 1, which was submitted to the department for review and consideration. This elopement was not as a result of lack of supervision for what is required of a special care unit not requiring one on one supervision or care, but rather was an isolated incident invoke by the individual alone in between rounds. There were no indicative precursors or warning signs showing escalation or any reason for enhanced supervision to be implemented at all in our rounds. The evidence provided in number one is not relevant to what is being stated as the violation. The individual was placed in our special care unit as a result of formal recognition from professional health care providers, and nothing listed in evidence one relates to a violation. The evidence listed in number 2 related to the UAI stating historical information on the resident also doesn?t directly relate to anything Carriage Hill did to violate this listed regulation. The issue of the UAI and ISP not matching is not accurately cited in this regulation, as this regulation relates to 460-D, involving adequate care and supervision not UAI and ISPs. This is addressed in the appropriate violation of the listed regulation. Number three is also just a point of reference. Number four is a summary of the report that we submitted to the state as a result of this elopement. It also references the distance from the community to where the resident was located insinuating a long walking distance. We have no proof that the resident walked to the location where he was found. Number five references a third-party website that states what the approximate temperature was on the day of the elopement which also seems irrelevant as evidence to how Carriage Hill violated this regulation. The resident was found, was unharmed, did not require hospitalization or further evaluation, and no new order were initiated as a result of this elopement. Moving forward, Carriage Hill will continue to follow the regulations, and care outlined for this resident by their medical providers to ensure his well-being and safety to the best of our ability.
Standard #:	22VAC40-73-680-K
Description:	Based on resident record review and staff interview, the facility failed to ensure that licensed health care professionals administer PRN medications and when medication aides administer PRN (as needed) medications when the facility has obtained from the resident?s physician or other prescriber orders that include symptoms that indicate the use of the medication and a detailed medication order that includes directions as to what to do if symptoms persist. EVIDENCE: 1. Physician?s order for resident 1, dated 12/10/2021, includes the following PRN medications: Acetaminophen 325 MG ? take two tablets by mouth every 4 hours as needed for pain, Banophen 50 MG (Benadryl) ? take one capsule by mouth every 6 hours as needed for allergies, Bisacodyl 5 MG tablet ? take 2 tablets by mouth every day as needed for constipation, Geri-Lanta Liquid ? take 30 MLs by mouth every 4 hours as needed for indigestion, Haloperidol 5 MG tab ? take one tablet by mouth every 6 hours as needed for agitation, Lorazepam 2 MG tablet ? take one tablet by mouth every 6 hours as needed for agitation and Nicotine 2 MG chewing gun ? chew one piece of gum every 4 hours as needed for nicotine withdrawl [sic]. The physician?s order also states ?Use PRN?s for agitation/behaviors before it escalates.? The aforementioned physician?s orders do not include descriptive symptoms or directions as to what to do if symptoms persist. 2. The order for the resident also includes the following: ?Diphenhydramine 50MG/ML Vial ? inject 1ML (50MG) intramuscularly every 6 hours as needed for muscle spasms.? Interview with staff 1 on 01/31/2022 revealed that the facility currently only employs registered medication aides (RMAs) and does not employ a licensed health care professional. The registered medication aide curriculum does not include training on administering intramuscular injections.
Plan of Correction:	The physician was consulted and the PRN orders were updated to include what to do if symptoms persist. Staff procedure in this instance is to call the medical provider to report for further instructions, and that has been reflected in writing on the order in the resident MAR. The order for the IM Diphenhydramine has been removed. This PRN order has never been exercised or administrated. Staff is aware to not accept any pending orders or enter them in our EMAR system if they exceed the capacity for the skillset of our RMA?s. Moving forward our NP will review and evaluate all orders to ensure they are appropriately within our scope of practice prior to them being accepted by the pharmacy for the property EMAR.