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: Feb. 9, 2022 and March 25, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Licensing Inspector (LI) conducted unannounced inspection in response to self-reported incidents that began on 2/9/2022 and concluded on 3/25/2022. Reviewed resident records staff records, inspected facility transport van, reviewed other documents and conducted staff interviews. Violation notice issued and assessed risk assigned to violations reviewed during the exit interview. Areas of non-compliance are identified on the violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the licensing office within 10 calendar days. 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
Description:	Based upon a review of documents and interviews, the facility failed to provide adequate care to protect the health, safety, and well-being of residents. Evidence: 1. On 2/3/2022 LI received an incident report from the administrator regarding an incident that took place on 2/2/2022 at approximately 10:35 am, involving a resident who was injured during a van transport for a resident outing. 2. LI spoke with the administrator via telephone on 2/4/2022 regarding the incident that was self-reported to LI on 2/2/2022. According to the administrator, the van was making a right turn when the back door of the van opened and the resident fell out. The administrator stated that the ?back door to the van appears not to have been latched properly and that the wheelchair was not adequately secured (buckled down) inside the van.? The administrator commented to LI that she believes that ?the wheelchair became loose, moved and hit the back door and the force caused the door to open and the resident fell out.? The administrator reported that local police did respond to the incident. The administrator stated that the resident suffered ?four broken ribs, a broken collar bone, and a head laceration requiring four staples in the back of his head and that the injuries were non-life threatening.? According to the administrator, the driver of the van has been employed with the facility for a couple of years but the van is a new van. LI was told by the administrator that along with the resident who was injured and the van driver, there were four other residents on the van plus another staff member. 3. The written statement from the van driver made on 2/4/2022 and provided to LI on 2/9/2022 stated that the driver ?loaded passenger on the bus, strapped (resident) floor belts on to wheel chair and drove off from Savin Hill Drive. Made turn onto Russell Branch drive and (Staff #2) said that (resident) had fallen on the ground, stopped bus and went to help him. I?m so sorry for this happening.? 4. LI interviewed Staff #2 on 2/9/2022. LI asked Staff #2 to provide details of what she saw when the residents were being loaded onto the van. Staff #2 acknowledged that she did not see the van driver fastening all four of the floor belts to the resident?s wheelchair and did not see the van driver latching the door because ?I was getting the other residents loaded onto the van and buckling them into their seats.? LI asked Staff #2 if she saw the resident fall out of the van and what she did when she realized the resident had fallen out. According to Staff #2, ?as the van was turning onto Russell Branch Parkway, I heard a gust of wind, turned around and saw the backdoor was open and resident was on the ground.? Staff #2 reported she then stood up and told the driver to stop the bus. Staff #2 stated that once the bus was stopped, she got off the bus and attended to the resident, who was ?lying on the ground in a fetal position and out of his wheelchair. The resident?s wheelchair was lying on the side walk to the left of the resident.? According to Staff #2 she began to assess the resident for injuries. The written statement for Staff #2 that was provided to the facility states ?We were pulling out of the stop sign and I look back and hear a loud thump and noise. I see the bus door open and (resident) outside on the road. We stopped the bus and I ran to him. He was answering all my questions! He said he was doing okay and remembers everything. From what I remember, resident was buckled and his brakes on his wheelchair locked.? The written statement of Staff #2 contradicts what was reported in her interview with LI on 2/9/2022 regarding her knowledge and observation of the resident being buckled and his wheelchair secured. Due to extensive information additional evidence is on a separate page.
Plan of Correction:	It is duly noted that the facility failed to provide adequate care to protect the health, safety, and well-being of Resident #1 while providing transportation in the facility bus. As noted in the Inspection Summary, the driver of the vehicle avers that he properly secured the resident in the van and also properly secured the back door of the vehicle consistent with his training prior to operating the vehicle. The driver had been driving residents at this community for over two years. During our investigation, we have not been able to ascertain the truth of the driver's statement. Despite the statements of the driver, because of the serious nature of the injuries suffered by the resident as a result of the driving of the vehicle, Tribute at One Loudoun has completed the following plan of correction: First, the driver of the vehicle has been terminated from his employment at the community. Second, the van was removed from service and sent to the manufacturer for a full inspection of all equipment to ensure the equipment is operable as intended. Once the van is returned to the community, the community will conduct an additional inspection to ensure all fasteners are functioning. This additional inspection will be conducted by at least maintenance personnel and supervised by the Executive Director. Third, enhanced training is being provided to all community drivers, including but not limited to, door latching, wheelchair tie down, wheelchair seatbelts and lift gate operations. Initial safety training will continue to occur upon hire and/or initial assignment to drive and bi-annually thereafter. The enhanced training will include a requirement that if there are two team members in the van for an excursion, each team member will be required to verify the secure fastening of the residents. Training records are a permanent part of the employee record. All potential drivers will be subjected to ongoing training and this enhanced training before the van will be put back into service. The training will be conducted by the Maintenance Director and supervised by the Executive Director.