VIRGINIA DEPARTMENT OF SOCIAL SERVICES

English Meadows Stephens City Campus
110 Spanish Oak Rd
Stephens city, VA 22655
(540) 868-0200

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: March 15, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

A non-mandated self-report-monitoring inspection was initiated on 03/15/2022and concluded on 03/24/2022. A self-reported incident was received by the department regarding allegations in the areas of resident care. The administrator emailed the LI documentation relating to the incident on 03/15/2022 and 03/19/2022. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and a violation was issued. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-680-D
Description:	Based on documentation, the facility failed to ensure medications are administered in accordance with the physician's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1. Documentation received from the facility administrator on 0315/2022 indicates resident 1 did not receive scheduled dose of Hydrocodone 7.5-325mg on 03/14/2022 at 9:00am due to medication not being available. 2. Documentation received from the facility administrator on 03/19/2022 indicates staff 1 documented administering Hydrocodone at 3:00am however, the Hydrocodone and narcotic count sheet were not available at that time. 3. Documentation received from the facility administrator on 03/19/2022 indicates staff 1 failed to notify pharmacy or resident care coordinator that the Hydrocodone and narcotic count sheet were not available at time of medication administration. 4. Documentation received from the facility administrator on 03/19/2022 indicates staff 2 was completing narcotic count with staff 1 for 7:00am-3:00pm shift on 03/14//2022 and Hydrocodone and narcotic sheet were not available for resident's 9:00am dose. Documentation indicates staff 2 notified resident care coordinator that the Hydrocodone and narcotic sheet were not available. 5. The LI interviewed the administrator on 03/24/2022 who confirmed Hydrocodone and narcotic count sheet were missing for resident 1 on 03/14/2022 and resident did not receive the scheduled 9:00am dose, however resident conveyed to administrator that her 3:00am dose of Hydrocodone was received.
Plan of Correction:	Staff 1 was separated from employment for failure to follow organization's incident reporting/policy/procedures and failure to comply with the VA Board of Nursing's Regulations Governing Medication Aides code 18VAC90-60-110. Standards of Practice (A. 1&3). ALFA conducted audit of all narcotics and narcotic count sheet. Mandatory meeting scheduled with all Registered Medication Aides on 4-06-2022 to review organization's Medication Management Plan and incident reporting requirements. Resident Care Coordinator is responsible to conducting random monthly med pass observations to ensure medications are administered in accordance with prescriber's orders.