VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Heritage Green Assisted Living
7080 Brooks Farm Road
Mechanicsville, VA 23111
(804) 746-7370

Current Inspector: Shelby Haskins (804) 305-4876

Inspection Date: Feb. 4, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

An unannounced self-reported incident monitoring inspection was conducted at the facility on February 4, 2022 from 9:12 a.m. to 9:52 a.m. Resident records, medication management plan, and elopement policy were reviewed. Additional documentation was provided by the facility post inspection. Staff interviews were also conducted. Violations were cited in the areas of resident care and related services. The Administrator was present onsite at the time of the inspection. I can be reached at alex.poulter@dss.virginia.gov or 804-662-9771.

Violations:

Standard #:	22VAC40-73-460-D
Description:	Based on record review and interview with staff, the facility failed to ensure attention to specialized needs, such as wandering from the premises. Evidence: 1. A self-reported incident was received 1-04-2022 that documented, ?Last night at 9pm, [Resident #3] (AL resident) unlocked the front doors and went outside in the parking lot. A person called 911 and [Resident #3] was brought back into the facility at 9:09pm by Sherriff. I had spoken to the deputy. When [Resident #3] returned into the community, we had noticed that [Resident #3] had abrasions. We sent [Resident #3] out to be assessed and they have admitted [Resident #3] for a UTI? they are going to admit him to receive IV antibiotics?? 2. Staff #1 stated that the Resident #3 was in jeans, a tee shirt, and sneakers when he was brought back by the Sherriff. The weather according to Accuweather.com in the zip code of the facility on 1-03-2022 was a low of 25 degrees Fahrenheit and a high of 52 degrees Fahrenheit. 3. Resident #3?s ?Report of Resident Physical Examination? dated 12-02-2021 documented Resident #3 has Alzheimer?s disease. 4. Staff #1 confirmed Resident #3 had wandered out of the building and went to the hospital as a result of the incident.
Plan of Correction:	Upon assessment at the hospital, it was confirmed that no serious injury resulted from the documented incident involving Resident #3. He is an AL resident who is independent in choosing his activities and is able to come and go as he pleases. In this instance, it was discovered he had a UTI which may have impacted his usually good judgement. He was sent to the hospital and admitted for the UTI, to begin treatment with IV antibiotics. The Executive Director and Resident Care Director conducted a staff in-service on Exit Seeking Behaviors. Incidents are reviewed at the Quarterly QA meetings on an ongoing basis, to address patterns or concerns.
Standard #:	22VAC40-73-640-A
Description:	Based on record review and interview with staff, the facility failed to implement the written plan for medication management. Evidence: 1. A self-reported incident dated 1-20-2022 read, ??. [Resident #1] is on hospice. Actively passing. RMA gave atropine drops to [Resident #1] for secretion yesterday evening. [RMA] pulled another residents atropine drops. Same dose, same medication different resident. Hospice, Dr, POA aware. Corrective action given and re educate 5 R?s. Of passing meds.? 2. The facility?s ?Medications? policy under the facility?s ?Policies and Procedures? updated 2018 documented: ?9. Medication administration must follow the 6 rights a. Right resident b. Right drug c. Right route d. Right time e. Right dose f. Right documentation.? 3. Staff #1 confirmed via email on 1-21-2022 that the error was discovered by Resident #1?s family member who was in the room at the time of the medication administration by Staff #2.
Plan of Correction:	The Resident Care Director has re-educated all RMAs to the 5 Rights of Medication Administration, including medications being administered in accordance of Physician orders and Board of Nursing Standards of Practice. Medication errors are reviewed at the Quarterly QA meetings on an ongoing basis, to address patterns or concerns.
Standard #:	22VAC40-73-680-D
Description:	Based on review of resident records and interview with staff, the facility failed to administer medications consistent with standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Evidence: 1. Staff #1 provided the facility?s ?Medication Error Report? dated 1-19-2022 that documented Resident #1 was administered Resident #2?s Atropine 1% Soln on 1-19-2022 at 3:40 p.m. Resident #1 and Resident #2 were both prescribed Atropine 1% drops per physician?s orders. 2. The ?Commonwealth of Virginia Board of Nursing Medication Aide Curriculum for Registered Medication Aides? revised May 21, 2013 under ?2.6 Identify the Five Rights of Medication Administration? documents: a. ?INTRODUCTION: The rules for giving medications are universal. We call these rules the ?Five Rights? of Medication Administration. These rules apply to every medicine, every client? A. The Five Rights 1. Right Client 2. Right Drug 3. Right Dose 4. Right Route 5. Right Time.? 3. Staff #1 confirmed that the current registered medication aide curriculum was not followed as the incorrect resident?s medication was administered to Resident #1.
Plan of Correction:	All RMAs were re-educated on the importance of medications being administered in accordance with physician orders and to ensure the 5 Rights of Medication Administration are followed, including the right drug and right person. Resident Care Director or designee will observe medication pass weekly to ensure continued compliance. Medication Compliance and Standards are reviewed at the Quarterly QA Meetings on an ongoing basis, to address patterns or concerns.