VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Hawksbill Assisted Living
122 N Hawksbill Street
Luray, VA 22835
(540) 743-6229

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: Oct. 13, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

A monitoring inspection was initiated on 10/13/2021 and concluded on 10/27/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 39. The inspector emailed the administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed three resident records, three staff records, fire drills, pharmacy review and criminal history reports submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-70-A
Description:	Based on a review of documentation and an interview, the facility failed to report to the regional licensing office, within 24 hours, any major incident that affected or that threatens the life, health, safety, or welfare of any resident. EVIDENCE: 1. Facility form, ?Resident Incident/Accident Report? prepared on 10/04/2021 at 9:15pm, indicated that resident 1 "roommate rang for resident staff, staff went in he was on the floor rounded up in a ball and hit his head on the night stand; complained of neck pain." 2. Nurse's note dated 10/04/2021 at 9:30pm "resident rounded out of bed, hit his head on night stand and is complaining of neck pain. He was in a ball when staff found him, they got him up and put him in bed, called family to let them know." 3. Nurse's note dated 10/05/2021 at 10:15am "NP upset that she wasn't called about resident 1 falling yesterday evening. Wants him sent out to be evaluated. Has bruising on both eyes and swelling above both eyes. Sent resident out at 10:20am" 4. This incident was not reported to the regional licensing office within 24 hours as required.
Plan of Correction:	Administrator will re-inservice staff on proper protocol after a fall or suspected fall. Post fall, suspected fall instructions are in med room and have each RMA review instructions and sign after reviewing.
Standard #:	22VAC40-73-470-F
Description:	Based on document review and an interview, the facility failed to ensure that when a resident suffers serious accident, injury, illness or medical condition, or there is reason to suspect that such has occurred, medical attention from a licensed health care professional shall be secured immediately. EVIDENCE: 1. Facility form, ?Resident Incident/Accident Report? prepared on 10/04/2021 at 9:15pm, indicated that resident 1 "roommate rang for resident staff, staff went in he was on the floor rounded up in a ball and hit his head on the night stand; complained of neck pain." 2. Nurse's note dated 10/04/2021 at 9:30pm "resident rounded out of bed, hit his head on night stand and is complaining of neck pain. He was in a ball when staff found him, they got him up and put him in bed, called family to let them know." 3. Nurse's note dated 10/05/2021 at 10:15am "NP upset that she wasn't called about resident 1 falling yesterday evening. Wants him sent out to be evaluated. Has bruising on both eyes and swelling above both eyes. Sent resident out at 10:20am" 4. There is no documentation indicating medical attention from a licensed health care professional was obtained immediately for resident 1. 5. An interview with the administrator on 10/26/2021 confirmed medical attention was not secured immediately for resident 1.
Plan of Correction:	Administrator will re-inservice staff on proper protocol after a fall or suspected fall. Post fall, suspected fall instructions are in med room and have each RMA review instructions and sign after reviewing.
Standard #:	22VAC40-73-680-D
Description:	Based on review of residents' records, the facility failed to ensure medications are administered in accordance with the physician's orders and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1. Resident 2 has the following order effective 09/27/2021-Eliquis 5mg tablet-Take one by mouth twice a day for A-fib. 2. The Medication Administration Record (MAR) for resident 1 indicates medication was not administered on 10/10/2021 through 10/17/2021 at 8:00am; 10/11/2021 and 10/14/2021 at 5:00pm due to "medication unavailable" 3. Page 185 #2b of the registered medication aide curriculum approved by the Virginia Board of Nursing indicates "every attempt must be made to get the drug and the attempt(s) must be documented.
Plan of Correction:	Administrator will remind staff of the need to be more accurate when documenting medication administration in order to correspond with the actual dates, times and to the safety of the resident. The administrator will check MARs on a random basis to maintain compliance.
Standard #:	22VAC40-73-680-E
Description:	Based on a review of residents' medication administration records, the facility failed to ensure procedures or treatments ordered by a physician or other prescriber are provided according to his instructions and documented. EVIDENCE: 1. Resident 2 has the following order effective 09/27/2021: Blood glucose testing-Check blood glucose two times daily at 6:00am and 4:00pm. Call if less than 70 or greater than 300. 2. Documentation in the Medication Administration Record (MAR) indicates resident's blood glucose level was 301 on 10/05/2021 at 6:00am; 306 on 10/07/2021 at 4:00pm; 337 on 10/14/2021 at 4:00pm; 316 on 10/15/2021 at 4:00pm. 3. There is no documentation that prescriber was notified of blood glucose readings above 300.
Plan of Correction:	Administrator will remind staff of the need to be more accurate when documenting medication administration in order to correspond with the actual dates, times and to the safety of the resident. The administrator will check MARs on a random basis to maintain compliance.