VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Spring Hills Mt. Vernon
3709 Shannons Green Way
Alexandria, VA 22309
(703) 780-7100

Current Inspector: Nina Wilson (703) 635-6074

Inspection Date: May 6, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

An unannounced complaint inspection was conducted on 5/6/22, in response to a complaint that was received by the licensing office on 4/22/22 regarding: Resident Care and Related Services. Facility documents and resident information were reviewed. Additional facility documentation was observed after the on-site visit. The allegation was determined to be valid, as a preponderance of evidence supported the allegation. The violation was discussed and an exit meeting was held. Areas of non-compliance are identified on the violation notice. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word 'corrected' is not acceptable. The 'plan of correction' must contain: 1) Steps to correct the non-compliance with the standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. Thank you for your cooperation and if you have any questions, contact me via e-mail at m.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on documentation, the facility failed to administer medication in accordance with the physician?s or other prescriber?s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing. Evidence: Resident #1?s record contained an order for Keflex, dated 2/8/22. Medication Administration Records (MARs), for Resident #1, were reviewed during the inspection. The order called for Resident #1 to receive one Keflex 500mg capsule, twice per day for 10 days. Facility records indicated that 20 Keflex capsules were sent to the facility for Resident #1. Resident notes indicate that the medication was first administered at 11:04 PM on 2/9/22. Resident #1?s MAR documented the administration of another 18 Keflex capsules. No documentation was provided, during the inspection, to indicate that Resident #1 received the last Keflex capsule that was ordered for her.
Plan of Correction:	Nurses were re-educated by the Director of Resident Care on medication transcription and administration protocol. An audit of residents MARs was conducted to ensure residents currently receiving ABT were not affected. Director of Resident Care will audit for new ABT orders 3 times per week for 8 weeks to ensure meds are transcribed and administered according to PCP order.