22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS
Technical Assistance:
1) Standard 460.H requires all residents be bathed at least twice a week. Discussed the admission form the families complete prior to admission and the need to add bathing twice a week as a standard requirement. 2) Any deviation from the standard must be addressed prior to implementation by completing and receiving approval of an allowable variance.
Comments:
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of ememrgency health pandemic declared by the Governor of Virginia.
A monitoring inspection was initiated on 5/3/21 and concluded on 5/26/21. A complaint was received by the department regarding allegations in the areas of resident care and related services. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and a violation was issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.
Based upon documentation and interviews, the facility failed to ensure one of three residents received the services specified in the individualized service plan (ISP).
Evidence: 1) The ISP (dated as completed 4/16/21) indicated resident A was to be bathed once a week. 2) Documents completed by the family/resident A indicated resident preferred to be bathed once a week. 3) The service received form indicated resident A received a shower on 4/20/21, 4/27/21 and 5/9/21; however, . on 5/26/21, the licensing inspector interviewed staff B who stated resident A did not receive a shower on 4/27/21. Staff B stated the service received form was signed off before the shower was given but when staff went in to resident A's room to give the shower, resident A refused due to Norovirus being in the building. 4) Neither a description of the circumstances warranting the deviation nor the date of the deviation were documented.in the resident's record. 5) Resident A's refusal was not documented. The deviation from the ISP was not documented in the resident's file and a notice of the deviation was not provided to the resident or the legal representative.
Plan of Correction:
1) ISP for resident A updated on 5/16/21 to reflect bathing schedule of two times per week. 2) Director of health and wellness, along with the memory care director and executive director, will ensure future resident ISPs reflect bathing schedules of twice weekly. 3) All direct care staff (DCS) will review the proper procedures for documentation of care, along with proper documentation of any deviation from the care plan, by 6/17/21.
Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.
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http://www.dss.virginia.gov/facility/search/alf.cgi