VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Auburn Hill at Swift Creek
5800 Harbour Lane
Midlothian, VA 23112
(804) 456-4455

Current Inspector: Coy Stevenson (804) 972-4700

Inspection Date: July 15, 2022

Complaint Related: No

Areas Reviewed:

? 22VAC40-73 GENERAL PROVISIONS ? 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES ? 22VAC40-73 PERSONNEL ? 22VAC40-73 STAFFING AND SUPERVISION ? 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS ? 22VAC40-73 RESIDENT CARE AND RELATED SERVICES ? 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS ? 22VAC40-73 BUILDINGS AND GROUND ? 22VAC40-73 EMERGENCY PREPAREDNESS ? 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS ? ARTICLE 1 ? SUBJECTIVITY ? 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS ? 63.2 GENERAL PROVISIONS ? 63.2 PROTECTION OF ADULTS AND REPORTING ? 63.2 LICENSURE AND REGISTRATION PROCEDURES ? 63.2 FACILITIES AND PROGRAMS ? 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES ? 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION ? 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT ? 22VAC40-80 THE LICENSE ? 22VAC40-80 THE LICENSING PROCESS ? 22VAC40-80 COMPLAINT INVESTIGATION ? 22VAC40-80 SANCTIONS

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/15/2022 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 6-08-2022 regarding allegations in the area(s) of: resident care and related services An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alexandra Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-680-D
Description:	Based on record review and interview with staff, the facility failed to ensure medications were administered in accordance with the physician's or other prescriber?s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing. Evidence: 1. Commonwealth of Virginia Board of Nursing Medication aide Curriculum for Registered Medication Aides, Revised May 21, 2013 Section 5.4 ?Document Medication Errors? reads, ?When one of the ?5 Rights? of medication administration becomes a ?wrong?, a medication error has occurred? When a medication is not given as prescribed by the HCP, a medication error has occurred. Errors are the opposite of the Five Rights and thus can be referred to as the Five Wrongs. They are: The Wrong Client ? the client receives another client?s medication?? 2. An email received with a final incident report dated 6-08-2022 documented the following occurred on 6-01-2022: ?[Resident #1] was given another resident?s medications. The medications were as follows: Carvedilol 12.5 mg, Aspirin 81 mg, Wellbutrin XL 300mg, Lasix 40mg, Levothyroxine .1mg, and Sertraline 100 mg? [Resident #1] experienced some nausea and vomiting initially?? Resident #1 did not receive her prescribed medications per the June 2022 Medication Administration Record (MAR). 3. Staff #1 confirmed via email and interview that the aforementioned incident took place and that Resident #1 was administered the wrong resident?s medications.
Plan of Correction:	On 6/1/2022, when a medication error was identified, the resident, her responsible party, and the physician were notified. On 6/1/22, The Director of Health and Wellness educated LPN and RMA staff on the rights of safe medication administration. Online education through the electronic education platform on "Avoiding Common Medication Errors" was assigned and completed by LPN and RMA staff. Medication Administration observations were conducted by the Director of Health and Wellness. The identified team member involved in the incident no longer works at the community. The Director of Health and Wellness or designee continues to monitor medication administration? through documentation review and medication administration observations as needed.