VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Our Lady Of Peace
751 Hillsdale Drive
Charlottesville, VA 22901
(434) 973-1155

Current Inspector: Angela Rodgers-Reaves (804) 662-9774

Inspection Date: Oct. 18, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Responding to an allegation regarding medication administration the inspector was on site on 10/18/2019 to conduct an investigation. Upon the arrival of the inspector, the facility Administrator and Executive Director were not on site, therefore the purpose of the inspection was discussed with a facility front office staff member. A morning medication administration pass was observed. Observations of the medication pass were discussed with the Executive Director and Assistant Director of Nursing upon their arrival to the facility. Based on the review of facility documentation and the staff interviews conducted it has been determined that the complaint is valid. The non-compliance revealed during this investigation is contained within this report. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and returned it to me within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word 'corrected' is not acceptable. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). If you have any questions please feel free to contact me at (804)662-9774 or by e-mail at Angela.r.reaves@dss.virginia.gov if you have any questions. The inspection was conducted between the approximate hours of 8:40a.m ? 2:16p.m

Violations:

Standard #:	22VAC40-73-680-D
Complaint related:	No
Description:	Based on a review of facility records and interviews with facility staff, the facility failed to ensure that medications were administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing stating that documentation is the ?6th Right? of medication administration and must address the administration, refusal or omission of medications using the correct forms and proper procedures. Evidence: The Medication Administration Records did not contain documentation indicating whether medication doses had been administered as indicated by the blank boxes on the MARs. Resident #1 October 2019 MAR Alcohol 2oz ? 1 out of 17 doses Atorvastatin 80mg tab ? 1 out of17 doses Eliquis 5mg tab ? 1 out of 35 doses Latanoprost 0.005% eye drops ? 1 out of 17 doses Sarna Senstive 1% lotion ? 1 out of 17 doses Senna Laxative 8.6mg tab ? 1 out of 35 doses Tizanidine HCL 2mg tab ? 1 out of 17 doses
Plan of Correction:	FACILITY RESPONSE- "The EMAR Dashboard ?Early, Late, Missed? report will be monitored throughout each shift by the Charge Nurse on duty. If a medication aide or licensed nurse is behind, the Charge Nurse will be responsible for helping ensure medications are administered in a timely manner. The Quality Assurance Nurse will review the ?Administration of Medications? policy with all medication aides and licensed nurses every six months. The Quality Assurance Nurse will complete a medication pass audit on all medication aides and licensed nurses once every six months, or more often if deemed necessary based on the results of the audit."