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: Nov. 15, 2023 and Dec. 19, 2023

Complaint Related: No

Areas Reviewed:

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: 11/15/2023, 11:30am to 12:29pm and 12/19/2023, 4:01pm to 4:06pm 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 09/19/2023 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: 60 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: 3 Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 4 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-B
Description:	Based on review of facility records and interview with staff, the facility failed to ensure medications shall remain in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident. EVIDENCE: 1. Per a note documented on the individual narcotic log on 09/18/2023, a multidose bottle of morphine was converted to prefilled syringes by hospice. 2. Per interview with staff #3, a hospice employee did convert the multidose bottle of morphine to prefilled syringes on 09/18/2023.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-D
Description:	Based on a review of facility records and interviews with staff, the facility failed to ensure medications shall be administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1. The Licensing Inspector (LI) received a facility self-report on 09/21/2023 stating resident #1 was prescribed morphine concentrate beginning 09/13/2023 and multiple nurses administered more morphine than prescribed to resident #1. 2. The original physician?s verbal order dated 09/13/2023 was documented as follows: Start morphine concentrate 100mg/5ml (20mg/ml), take 0.5ml SL q one hour prn (as needed) for pain or shortness of breath. The order was signed on 09/14/2023 and stated, ?please dispense individual syringes.? 3. A verbal order given on 09/16/2023 was documented as follows: D/C previous morphine orders. Morphine scheduled 0.5ml (10mg) ? take 2 prefilled syringes (20mg) every 4 hours. Increase prn 0.5ml from every hour as needed to 20mg (1ml) every 15 min as needed (2 prefilled syringes). Morphine to be given SL. The signed order was provided to the facility 09/26/2023. 4. Per interview with staff #1, prefilled ?half? syringes with 10mg morphine were being used to administer the medication as ordered in item number two (above). Staff #1 reported when the new order changed the dose to 20mg, two syringes prefilled with 10mg of morphine were being given, until the supply ran out. Staff #1 reported after all the prefilled syringes were used, the pharmacy sent a bottle of the prescribed morphine to the facility. 5. Per interview with staff #2, resident #1 was receiving two 0.5mL prefilled syringes of morphine as ordered in item number three (above) until the supply on hand ran out. Staff #2 reported the supply was depleted during night shift and the pharmacy sent a bottle of the prescribed morphine to the facility. Staff #2 reported night shift staff notified oncoming day shift staff that two syringes of morphine were being given to resident #1, and staff were drawing up the morphine out of the bottle provided by the pharmacy. 6. According to the individual narcotic log: a. The final dose of two prefilled 0.5mL syringes was given on 09/17/2023 at 7:10pm. b. On 09/18/2023, 1mL of morphine (20mg/mL) was given at the following times: 4:15am, 4:30am, 4:45am, 5:00am, 6:00am. c. On 09/18/2023, 2mL of morphine (20mg/mL) was given at the following times: 7:19am, 8:37am, 9:19am, 10:20am, 11:15am, 11:40am, 12:05pm, 12:20pm, 12:40pm, 1:00pm, 1:15pm, 1:30pm, 2:10pm, 3:00pm, 3:30pm.
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 December 19, 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 and #2 were counseled and provided a written corrective action notice on 09/20/2023. Additional training will be provided to staff #1 and #2 regarding medication administration guidelines with specific focus on narcotics no later than 01/31/2024. Random audits/monitoring will be conducted by the Health 01/31/2024. [SIC]