VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Village at Woods Edge
1401 North High Street
Franklin, VA 23851
(757) 562-3100

Current Inspector: Lanesha Allen (757) 715-1499

Inspection Date: Sept. 16, 2020 , Sept. 17, 2020 and Sept. 18, 2020

Complaint Related: No

Areas Reviewed:

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 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-90 The Criminal History Record Report

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 09-16-2020 and concluded on 09-18-2020. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 42. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 3 resident records, 3 staff records, criminal background checks and sworn disclosures of newly hired staff, staff schedules, fire drills, fire and health inspection reports, dietary oversight, and healthcare oversight submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-650-C
Description:	Based on record review and interview, the facility failed to ensure the physician's or prescriber?s oral orders are reviewed and signed by a physician or prescriber within 14 days. Evidence: 1. Staff #1 provided a copy of resident #2?s telephone orders; however, the following orders were not reviewed and signed by a physician or prescriber within 14 days: A. A telephone order dated 08-20-2020 which documented ?Cleanse skin tear to the right forearm daily with dermal wound cleanser. Pat dry. Apply TAO (a pea size amount), apply a non-stick pad, wrap with kling and secure with tape. Check daily for signs of infection (fever >99 degrees F, redness, swelling) Dx. Skin tear? The order was not signed by a physician until 09-15-2020. B. A telephone order dated 08-24-2020 which documented ?Anti-Diarrheal tablet 2mg take 1 tab PO QID PRN as needed. Call MD if symptoms persist more than 24 hours. DX: Diarrhea.? The order was not signed by a physician until 09-15-2020. 2. Staff #1 acknowledged resident #2?s aforementioned telephone orders were not reviewed and signed by the physician or prescriber within 14 days.
Plan of Correction:	The facility will ensure that physician orders are reviewed and signed by the physician or prescriber within 14 days. The facility does not have a medical director, but will problem solve the best way to reach the physician by letter of reminders, faxing, multiple attempts with reminders to return telephone orders as reviewed and signed. Records will be audited to ensure physician or prescriber orders have been signed timely.
Standard #:	22VAC40-73-680-D
Description:	Based on record review and interview, the facility failed to ensure medications are administered in accordance with the physician's instructions. Evidence: 1. Resident #1?s current physician?s orders dated 08-31-2020 documented ?Acetaminophen 325mg tablet (Original order date 4/19/2020)- Take 2 tabs (650mg) by mouth every 6 hours as needed [PRN] for pain for if symptoms persist > than 24 call MD.? 2. Resident #1?s September 2020 Medication Administration Record documented the following: A. On 09-13-2020, direct care staff documented the PRN Acetaminophen 325mg was administered at 1:50 PM and 7:35 PM; which was not every 6 hours as needed per the physician?s instructions. B. Staff administered the PRN Acetaminophen 325mg for ?back pain? on 09-01-2020 at 4:03 PM; 09-02-2020 at 6:01 AM; 09-03-2020 at 2:17 AM; 09-03-2020 at 4:01 PM; 09-04-2020 at 5:13 AM; 09-05-2020 at 12:26 AM; 09-05-2020 at 9:21 AM; 09-05-2020 at 4:14 PM; 09-06-2020 at 9:11 AM; 09-06-2020 at 3:50 PM; 09-07-2020 at 4:27 PM; 09-08-2020 at 6:10 AM; 09-08-2020 at 11:17 PM; 09-09-2020 at 5:51 AM; 09-10-2020 at 1:26 AM; 09-10-2020 at 10:43 AM; and 09-11-2020 at 12:13 PM. C. When asked if resident #1?s physician was notified of the resident?s back pain due to symptoms persisting greater than 24 hours, staff #1 stated the physician was notified on 09-11-2020. Staff #1 could not verify or provide documentation that the staff notified the physician of resident #1?s daily back pain from 09-01-2020 to 09-10-2020. 3. Staff #1 acknowledged resident #1?s PRN Acetaminophen 325mg was not administered in accordance with the physician?s instructions and that the staff did not notify the physician of the resident?s back pain if the symptoms persisted greater than 24 hours.
Plan of Correction:	The Plan of Correction will be that the physician orders will be followed as instructed. The facility staff will be educated by the Supervisor (RN/LPN) to follow physician instructions as the order is written and to follow the five rights of medication administration by the Board of Nursing. Staff twill be educated to note PRN time frames of physician orders correctly and to administer !he medication as instructed by physician. The facility will educate staff if the resident continues with pain which is not relieved by the pain medication in the time frame ordered by the physician; then the physician shall be notified accordingly; which will be documented in the resident record of the notification, and the instructions to follow. The physician was notified on 9/18 and a routine order for Acetaminophen 325mg (2) tabs (650mg) by mouth was ordered twice daily for pain management. Also ordered by the physician was Acetaminophen 325mg (2) tabs (650mg) BID by mouth as needed for pain.
Standard #:	22VAC40-90-40-B
Description:	Based on staff record review and interview, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee. Evidence: 1. Staff #1 provided a list of newly hired staff and dates of hire, which included staff #5 was hired as a Personal Care Aide (PCA) on 05-07-2020. 2. Staff #5?s ?Virginia State Police Detail Report Central Criminal Records Exchange? form was dated 02-28-2020. Staff #1 could not provide an additional criminal history record report that was obtained on or prior to the 30th day of staff #5?s employment. 3. Staff #1 stated ?another background check was not done? for staff #5. Staff #1 acknowledged staff #5?s criminal history record report was not obtained on or prior to the 30th day of employment.
Plan of Correction:	The facility will obtain a criminal background check of all new hire employees on or prior to the 30th day of employment.