VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brookdale Bristol
375 Liberty Place
Bristol, VA 24201
(276) 669-1111

Current Inspector: Rebecca Berry (276) 608-3514

Inspection Date: Aug. 2, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/02/2023, 2:12pm to 3:35pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 06/07/2023 regarding allegations in the area(s) of: Resident care and related services, medication administration Number of residents present at the facility at the beginning of the inspection: 55 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-680-D
Description:	Based on facility self-report and a review of resident and facility records, the facility failed to administer medications in accordance with the physician?s or other prescriber?s instructions and consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1. Per the physician?s order dated 06/01/2023, resident #1 was prescribed Lorazepam (Ativan) 0.5mg tablet, take 4 tablets (2mg total) by mouth every 12 (twelve) hours for 14 days. 2. Per the June 2023 Medication Administration Record (MAR) for resident #1, the instructions state Ativan Oral Tablet 0.5 mg (Lorazepam), give 4 tablets by mouth two times a day for anxiety/squamous cell carcinoma of the lung for 14 days. 3. Per facility self-report, resident #1 was prescribed Lorazepam 2mg to be administered at 8pm. The medication was packaged as 4 - 0.5mg tablets in each dose. Staff #1 misunderstood the order and administered four doses (8mg total) in error on 06/05/2023, 7:04pm. 4. Per facility documentation and interviews with staff #2 and staff #3, staff #3 discovered the error on 06/06/2023. The situation was addressed with staff #1, who did admit to the error.
Plan of Correction:	The following is a summary of the Plan of Correction for Brookdale Bristol. This Plan of Correction is in regards to the Corrective Action Report dated August 02, 2023. This correction is not to be construed as an admission of or agreement with any findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regulatory requirements. In this document, we have outlined specific actions in response to each allegation or finding, nor have we identified any mitigating factors. ? Staff #1 who made the error was counseled and provided a written corrective action notice on 06/07/2023. ? Additional training will be provided to staff #1 regarding medication administration guidelines with specific focus on narcotics no later than 08/31/2023. ? Random audits/monitoring will be conducted by the Health and Wellness Coordinator/designee for three months to verify compliance with the community?s medication administration guidelines. [SIC]