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: Feb. 23, 2022 and March 17, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS

Comments:

An unannounced monitoring inspection was conducted on February 23, 2022 from 1:10 p.m. to 1:40 p.m. in response to self-report incidents of resident elopement. The Executive Director was present. Resident record was reviewed and a tour of the Safe Secure Environment and areas of elopement were toured. Violation(s) were found in the area of Resident Care and Related Services. Thank you for your cooperation with this inspection. I can be reached at alex.poulter@dss.virginia.gov or 804-662-9771 with any questions.

Violations:

Standard #:	22VAC40-73-450-A
Description:	Based on record review, the facility failed to ensure the preliminary plan of care addressed the basic needs of the resident that adequately protects his health, safety, and welfare. Evidence: 1. Resident #1?s ?72 HOUR Individualized Service Plan (ISP) dated 2-02-2022 did not identify a Safe, Secure Environment (SSE) placement as its own individual service need; however, the ?Assessment of Serious Cognitive Impairment? that was completed Physician #1 documented Resident #1 has a serious cognitive impairment due to a primary psychiatric diagnosis of dementia and is unable to recognize danger or protect [Resident #1?s] own safety and welfare. 2. Additionally, Resident #1?s ISP identified the resident as an Elopement Risk, but does not address the steps to be put in place to prevent an elopement and documented, ?Will reside within memory care.?
Plan of Correction:	The 72 Hour Individualized Service Plan (ISP) has been revised to include the identification of when a resident needs a Safe, Secure, Environment (SSE). Additionally, the ISP has been revised to include the steps put in place to prevent an elopement when a resident is identified as an elopement risk.
Standard #:	22VAC40-73-460-D
Description:	Based on record review and observation, the facility failed to provide attention to specialized needs, such as wandering from the premises. Evidence: 1. Resident #1 admitted 2-02-2022 to the Safe Secure Environment of the facility. Resident #1?s Uniform Assessment Instrument (UAI) dated 1-26-2022 documented under Behavior Pattern, ?Wandering/Passive ? Weekly or more?. Additionally, Resident #1?s Individualized Service Plan (ISP) dated 1-26-2022 documented ?Yes? on ?Elopement Risk?. 2. An incident report received 2-03-2022 by the facility documented that on 2-03-2022 at 11:00 a.m., ??elopement; the staff was alerted to an alarm going off on the side entrance door. The resident [Resident #1] was observed walking around the side of the building towards the front entrance. The resident was escorted back into Memory Care.? ?Nurse?s Notes? dated 2-03-2022 by Staff #2 documented, ??.Resident [#1] walked out of side door and came back into lobby. Was seen by concierge staff and was escorted back into memory care?? 3. An incident report was received on 2-18-2022 regarding the elopement that occurred that day at 12:20 p.m. that stated, ?? elopement; at approximately 12:20 p.m., the community received a call from the Henrico Police Department stating that they had found the resident [#1] walking along interstate-64?? In the email, Staff #1 documented, ?[Resident #1] will have 24-hour one-on-one sitters from now until the time [Resident #1?s] family is able to find alternate placement for him?? 4. Staff #1 confirmed via email on 2-20-2022 that Resident #1 physically moved out of the community. Staff #1 confirmed during inspection that Resident #1 eloped the facility two times in a 21 day period. Staff #1 confirmed during inspection that Resident #1 was an elopement risk and had repeated elopements and elopement attempts as documented above.
Plan of Correction:	The community will provide attention to specialized needs, such as wandering from the premises, by documenting the specialized needs in the resident?s care plan, along with a course of action to ensure specialized needs are monitored closely by all staff members in the community. The care plan will include a plan-of-action to ensure specialized needs are identified and addressed.
Standard #:	22VAC40-73-930-D
Description:	Based on interview with staff, the facility failed to ensure for each resident with an inability to use the signaling device, the inability shall be included in the resident's individualized service plan and the plan shall specify a minimal frequency of daily rounds to be made by direct care staff. Evidence: 1. Resident #1?s individualized service plan (ISP) dated 2-02-2022 did not specify a minimal frequency of daily rounds to be made by direct care staff. 2. Additionally, Resident #1?s inability to use the signaling device was not on the resident?s ISP. 3. Staff #1 confirmed ?if a resident is unable to use a call pendant to request help we complete rounds and document in their care plans. Our standard is 2-hour rounds for memory care.?
Plan of Correction:	Going forward, if a resident is unable to use a signaling device, it will be documented in their individualized service plan and will specify a minimal frequency of daily rounds to be made by direct care staff.