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: Sept. 21, 2020 , Sept. 23, 2020 , Oct. 7, 2020 and Oct. 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 September 21, 2020 and concluded on October 9, 2020. A self-reported incident was received by the department regarding allegations in the area of resident supervision. 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 record review and staff interview, the facility failed to ensure supervision was provided to a resident with serious cognitive impairment due to dementia and resident on the facility's safe, secure environment. Evidence: 1-On 9-4-20, according to the self-report incident document, a ?resident exited the front door behind a staff member?? The resident is later identified as resident #1, who reside on the safe, secure unit (scu). a-Resident, assessed as needing placement on the facility?s memory support unit (safe, secure unit). Resident #1?s individualized service plan (ISP) dated 5-18-20 indicated resident ?requires supervision with mobility, resident will have escort/companion at all times when out of the MS home, services provided by direct care staff..? Resident disoriented some spheres all the time (time/place) as indicated on resident? uniformed assessment instrument (uai) dated 5-18-20. 2-Interview with staff #1 on 9-21-20, staff stated resident followed staff #2 off the unit as viewed on the video footage. Staff #1 stated, the resident was not gone very long before staff #3 returned resident to safe, secure building. 3-Interview with staff #2 on 9-30-20, staff stated being at work on 9-4-20 in the memory support unit, received call to report to the assisted living unit (AL) for work. Staff stated leaving unit, not looking back as staff left the memory support building. 4.Interview with staff #3 on 10-7-20, staff stated being in the parking lot of the Assisted Living building when approached by resident #1. Staff #3 recognized resident was from the memory support unit. Staff spoke with resident #1 and took resident back down the hill to the memory support unit. 5-A review of the video footage provided by staff #1 of the area on 9-4-20 was conducted with the following observations: Staff #2 is observed exiting the building from the courtyard side of the memory support building. Later another individual, identified as resident #1 is seen exiting the safe, secure building from the same door as staff #2. Staff is walking in the street in the direction toward the assisted living building. Resident #1 is also seen walking on the sidewalk and going in the same direction. The staff and the resident disappears from the video at 3:17:59 pm. The video resumes at 3:18:59 pm, however, staff #2 and resident #1 are no longer in view. Multiple cars are observed going up and down the street. Cars are also observed going into the parking lot and multiple staff going in and out of the memory support at two entrances that can be observed in the video. Two individuals are observed entering the memory support building at the entrance with a covering/awning. According to staff #1, the individuals are staff #3 and resident #1. 6-On 9-4-20, resident #1 exited the facility?s memory support unit (safe, secure unit) and was outside of the unit, unsupervised. The area where the facility is located is surrounded by wooded areas all around. The video showed, on the day and time, the street was busy with cars coming and going up and down the hill to the memory support. Cars are also observed going onto and from the side street to the memory support building. The video also showed traffic coming and going as staff #3 escorted resident #1 back to the Memory Support Unit. 7-According to staff #4, staff #1 exited the locked unit that has a delayed timer which allows individuals to safely exit. As staff exited the unit, staff did not look back to check to see if the door was secure or if a resident was near the door. The resident was able to exit the unit behind the staff, go through the vestibule area located outside the secure unit and exit the door leading outside on the courtyard.side of building. 8. On 10-9-20, staff #1 and #4 acknowledged resident exit the scu, unescorted.
Plan of Correction:	1. Re-education was provided to staff on when entering or exiting the unit you must wait until door closes and locks before moving on. (9-4-2020) 2. Signs placed on door to stoop and ensure no one is following you out the building when exiting. (9-20-2020) 3. Access code removed from key Pad and all access must be allowed by staff scanning badge. All access must be monitored until door is closed and secured. (9-30-2020) 4. Facilities came and adjusted door closure time to decrease the time door remain accessible for exiting. (9-30-2020) 5. All staff have been educated on entering only through the staff entrance to decrease potential of elopement. (9-30-2020)