VIRGINIA DEPARTMENT OF SOCIAL SERVICES

WoodHaven At Williamsburg Landing
5500 Williamsburg Landing
Williamsburg, VA 23185
(757) 253-0303

Current Inspector: Willie Barnes (757) 439-6815

Inspection Date: Feb. 27, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

An unannounced monitoring inspection was conducted on 2-27-20 (ar 11:00 am/dep 5:30 pm). Resident record and staff record reviewed. Interviews conducted with staff regarding medication error. An exit was conducted on 2-27-20 with the administrator. The acknowledgement form was signed by the administrator. Please complete the 'Plan of Correction' and 'Date to be Corrected' for each violation cited on the violation notice and return it to me within 10 calendar days from today (3-29-20). You need to be specific with how the deficiencies either have been or will be corrected to bring you into compliance with the Standards. Your plan of correction must contain the following three points: 1. Steps to correct the noncompliance with the standard(s) 2. Measures to prevent the noncompliance from occurring again 3. Person(s) responsible for implementing each step and/or monitoring any preventive measure(s) Please provide your responses in a Word Document, if possible.

Violations:

Standard #:	22VAC40-73-680-D
Description:	Based on record review and staff interview, the facility failed to ensure medication for a resident was administered in accordance with the physician's order 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. Evidence: Evidence: 1. 2-27-20, a review of resident #1's record was conducted with staff #2 and #3. According to facility document provided and staff #2's interview, staff #4 documented taking resident's blood sugar (glucose monitoring) on 2-4-20; 2-7-20 and 2-11-20. 2. According to staff #2, a review of resident #1's glucometer reading, the machine did not have recordings for 2-4-20, 2-7-20, and 2-22-20 as recorded by staff #4. Further check of the house glucometer did not indicate readings on the aforementioned dates for blood sugar readings. 3. On 3-2-20 during interview, staff #4 stated using a glucometer in the medication room, but could not state to whom the glucometer belong and stated the glucometer used was not labeled. 4. A review of resident #1's February 2020 medication administration record (mar) and physician's order dated 5-9-19, resident #1's blood sugar is taken three times a day. Resident is prescribed Humalog to be administered per scale based on blood sugar (glucose) reading. 5. Staff #1 and #2 stated resident's blood sugar reading not taken on days staff #4 worked according to history report from resident #1's glucometer and no readings on the facility's house monitor.
Plan of Correction:	All nurse and medication aides will be in-serviced on the proper way to Administer the resident's medications according to the physician's orders. Manager of Memory Support and Administrator will ensure compliance by checking the Glucometers every 24 hours for next 6 months and document in chart.