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: Dec. 9, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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 monitoring inspection was initiated on August 23, 2020 and concluded on October 9, 2020. A self-reported incident was received by the department regarding allegations in the area of 22VAC40-73-450-C. The manager of the safe, secure unit was contacted by telephone to conduct the investigation. The licensing inspector emailed the manager a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and a violation was issued. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-460-D
Description:	Based on document review, video review and staff interview, the facility failed to ensure supervision was provided to resident with serious cognitive impairment due to dementia who resided on the facility?s safe, secure environment. Evidence: 1.On 8-19-20, according to the self-report incident document, staff #1 was in the office and observed through the office window, the spouse of resident #1 drive up to the facility parking lot. Staff #1 also observed, a man with a walker approached the car. The man was observed by staff #1, to be resident #1 from the memory support unit. Staff #1 alerted the manager of the safe secure unit of what she observed. a. Resident #1 assessed as needing placement on the facility?s memory support unit (safe, secure unit). Resident #1?s individualized service plan (ISP) dated 4-21-20 indicated, ?resident #1 assessed with mechanical help and supervision with mobility, ?resident will have escort/companion at all times when off the unit??? staff and wife to provide services when off the unit.. ?. Resident #1 is also assessed as having dementia and disoriented sometimes to time. 2 Interview with staff #1 on 9-3-20 and 9-10-20, staff #1 was asked if staff was aware resident #1 was in the Adult Day Care Center (ADCC) area of the building. Staff stated, no, not aware that resident was in the area. Staff #1, stated not having visual contact or knowledge of staff from the memory support unit being in the ADDC area. Interview with staff #2 on 9-10-20, staff stated being told by the activities director of the memory support, to take resident #1 downstairs (ADDC visiting area) because resident was scheduled for a 2:00 pm visit with spouse. Staff #2 and staff #3 took resident downstairs to the waiting area in the ADCC building and left the resident in the visitor?s room and went back upstairs to the memory support unit. Staff #2 stated not informing staff #1 that resident #1 was in the area because ?staff #1 and another ADCC staff took care of visits.? Staff #2 also stated hearing someone in the office in the ADDC area talking and assumed it was staff #1, but did not check to see if it was staff #1. Staff #2 and #3 stated did not speak with or make any contact with staff #1 when resident #1 was left. Interview with staff #3 on 9-10-20, Staff #3 provided the same statements as staff #2 regarding taking resident #1 from the memory support unit to ADCC waiting area and left the resident. 3.The investigation revealed resident #1 was escorted from the memory support unit, the facility?s safe, secure unit, by staff #2 and #3. Staff left resident #1, unattended, unsupervised in the area and went back upstairs without making contact making contact with the spouse or a staff member. The resident was later observed by staff #1, going up to a car in the parking lot of the facility.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-460-D
Description:	Based on document review, video review and staff interview, the facility failed to ensure supervision was provided to resident with serious cognitive impairment due to dementia who resided on the facility?s safe, secure environment. Evidence: 1.On 8-19-20, according to the self-report incident document, staff #1 was in the office and observed through the office window, the spouse of resident #1 drive up to the facility parking lot. Staff #1 also observed, a man with a walker approached the car. The man was observed by staff #1, to be resident #1 from the memory support unit. Staff #1 alerted the manager of the safe secure unit of what she observed. a. Resident #1 assessed as needing placement on the facility?s memory support unit (safe, secure unit). Resident #1?s individualized service plan (ISP) dated 4-21-20 indicated, ?resident #1 assessed with mechanical help and supervision with mobility, ?resident will have escort/companion at all times when off the unit??? staff and wife to provide services when off the unit.. ?. Resident #1 is also assessed as having dementia and disoriented sometimes to time. 2 Interview with staff #1 on 9-3-20 and 9-10-20, staff #1 was asked if staff was aware resident #1 was in the Adult Day Care Center (ADCC) area of the building. Staff stated, no, not aware that resident was in the area. Staff #1, stated not having visual contact or knowledge of staff from the memory support unit being in the ADDC area. Interview with staff #2 on 9-10-20, staff stated being told by the activities director of the memory support, to take resident #1 downstairs (ADDC visiting area) because resident was scheduled for a 2:00 pm visit with spouse. Staff #2 and staff #3 took resident downstairs to the waiting area in the ADCC building and left the resident in the visitor?s room and went back upstairs to the memory support unit. Staff #2 stated not informing staff #1 that resident #1 was in the area because ?staff #1 and another ADCC staff took care of visits.? Staff #2 also stated hearing someone in the office in the ADDC area talking and assumed it was staff #1, but did not check to see if it was staff #1. Staff #2 and #3 stated did not speak with or make any contact with staff #1 when resident #1 was left. Interview with staff #3 on 9-10-20, Staff #3 provided the same statements as staff #2 regarding taking resident #1 from the memory support unit to ADCC waiting area and left the resident. 3.The investigation revealed resident #1 was escorted from the memory support unit, the facility?s safe, secure unit, by staff #2 and #3. Staff left resident #1, unattended, unsupervised in the area and went back upstairs without making contact making contact with the spouse or a staff member. The resident was later observed by staff #1, going up to a car in the parking lot of the facility.
Plan of Correction:	Resident #1 was escorted from the memory support unit, the facilities safe, secure unit, by staff #2 and #3. Staff left resident #1, unattended, unsupervised in the area and went back upstairs without making contact with the spouse or a staff member. The resident was later observed by staff #1, going up to a care in the parking lot of the facility. 1.Education has been provided to all Memory Support staff on how Memory Support residents should be monitored at all times, the appropriate handing off custody of the resident to another person, and the importance of ensuring awareness of the individual receiving resident to be monitored for safety. 9-10-20 2.Visitation has been moved back to Memory Support to ensure resident safety. 10-4-20 3.Staff member #2 and #3 have been disciplined and educated on the severity of their actions. 8-18-20 4. All new hires will receive education on the appropriate protocol with handing a memory support resident off in a different location.