VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Bentley Commons at Lynchburg
1604 Graves Mill Road
Lynchburg, VA 24502
(434) 316-0207

Current Inspector: Angela Marie Swink (276) 623-6575

Inspection Date: April 1, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

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 04/01/2021 and concluded on 05/05/2021. A self-reported incident was received by the department regarding allegations in the areas of Resident care and related services and mixed population. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator 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 violations were 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 #:	22VAC40-73-1040-A
Description:	Based on a review of resident records and staff interviews, the facility failed to ensure that a system of security monitoring of residents with serious cognitive impairments, such as door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, or delayed egress mechanisms were available on all doors leading to the outside. EVIDENCE: 1. The facility serves a mixed population as indicated by the record for Resident 1, who was admitted to the facility on 10/26/20. The history and physical dated 10/20/2020 in the record for resident 1 had documentation that resident 1 has a diagnosis of Dementia, has confusion and poor short term memory. 2. The uniform assessment instruments (UAI's) completed on 10/26/2020 and again on 03/26/2021 for resident 1 had documentation that the resident is disoriented to some spheres some of the time with time, date and place being the spheres affected and that the resident requires supervision with mobility. 3. The individualized service plans (ISP's) dated 10/26/2020 and 03/26/2021 in the record for resident 1 had documentation under mobility that the resident requires supervision with mobility and will receive supervision from POA/RP/Family and all staff to include redirecting, cueing and prompting when outside of the community. The ISP also had documentation of the residents disorientation to time, date and place and has services listed that resident 1 will be reoriented to time, date and place by the use of a clock/watch, calendar, facility literature and verbal cueing. 4. The record for resident 1 has documentation in resident notes of the resident being found off of the facility grounds on 03/09/2021. Progress notes dated 03/30/2021 had documentation that resident 1 again left the building and was found off of the facility grounds. 5. In a phone interview with staff person 1 on 3/30/2021 it was noted that the facility did not have a system of security monitoring of residents with cognitive impairments on facility doors leading to the outside.
Plan of Correction:	Cameras currently already installed inside and outside of premises of facility. Alarms were immediately installed on all exit doors on first floor to alert staff that residents are or attempting to exit the building. Proper door signage decals will be placed on all stairwell doors within facility as well as all exit doors leading outside of facility. The signs wills also be placed on every door inside facility in which resident could be potentially harmed if entering. (6/5/21) Administrator is contracting with fencing company to install fencing in back yard area of building to place an enclosure so that all residents can enjoy the outdoors and their freedom of movement is not affected. Administrator will contact fire marshal to ensure that proper locking mechanisms are installed on fencing as well. Administrator will notify Licensing Inspector when proper enclosure installation is completed. Administrator and Director of Nursing will continue to monitor behaviors and need for any additional interventions and implement as needed.
Standard #:	22VAC40-73-70-A
Description:	Based on a review of resident records the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. EVIDENCE: 1. The record for resident 1 contained documentation in resident notes that on 03/09/2021, the resident was transported to the local hospital by EMS after being found on the ground, off site with injuries to the right side of her face and shoulder complaints. As of the date of this inspection, the facility had not reported this incident to the regional licensing office.
Plan of Correction:	Administrator will report within 24 hours any incident that results in resident being transported to hospital and/or could effect the health, safety, or wellness of resident or incidents that result in significant injury.
Standard #:	22VAC40-73-450-H
Description:	Based on a review of resident records, the facility failed to ensure that care and services specified in the individualized service plan (ISP) were provided. EVIDENCE: 1.The ISP's dated 10/26/2020 and 03/26/2021 in the record for resident 1 had documentation under mobility that the resident requires supervision with mobility and will receive supervision from POA/RP/Family and all staff to include redirecting, cueing and prompting when outside of the community. 2. In a phone call with staff person 1 on 03/30/2021 it was expressed that the facility was aware that resident 1 sometimes walked outside by herself to enjoy the weather. 3. The record for resident 1 had documentation in resident notes of the resident being found on the ground outside of an adjacent facility by that facility's staff on 03/09/2021, and that facility's staff called local EMS. Dispatch contacted this facility and made them aware of resident 1's location and of the incident that had occurred. Documentation in resident notes indicated that Resident 1 had expressed that she had walked outside to enjoy the weather. The resident notes also indicated that resident 1 was transported by EMS to the local hospital for evaluation of injuries to the right side of her face and shoulder complaints. 4. The record also had documentation in progress notes that on 03/30/2021 resident 1 wandered from the facility grounds and was found on the main road by a local citizen. The progress notes also indicated that resident 1 was not able to express to the citizen where she lived so the citizen contacted the local police for assistance to determine where resident 1 resided. 5. It was noted that the specified services listed on resident 1's ISP for mobility to include supervision from POA/RP/Family and all staff to include redirecting, cueing and prompting when outside of the community were not provided when resident 1 left the facility on 03/09/2021 or 03/30/2021.
Plan of Correction:	Administrator conducted immediate action for resident safety to include reassessment that included discharge of resident due to not being appropriate for assisted living. Around the clock caregivers were initiated as well to remain with resident until discharge. Alarms were immediately installed on all exit doors on first floor to alert staff that residents are or attempting to exit the building. Administrator and Director of Nursing initiating an elopement log book to be available at front desk. Elopement book will include all residents with a cognitive impairment diagnosis and is at risk for elopement or wandering. The elopement book will FACE sheet with a verbal description of resident. It will also include two pictures of resident to include one profile and one full body picture.(6/5/21) Administrator and Director of Nursing initiated a rounding log book for staff to routinely monitor all residents with a diagnosis of a cognitive impairment and at risk for elopement or wandering.(6/5/21) Administrator to initiate elopement drill within facility to aide staff with education of steps to take if any resident elopes or wanders. These elopement drills will be begin within 30 days of inspection and will continue to be conducted and results documented quarterly.(6/5/21) Staff will be provided with additional training in the case of a resident eloping or wandering. This training will be provided as an in-service during the elopement drills conducted quarterly. (ongoing)
Standard #:	22VAC40-73-460-D
Description:	Based on a review of resident records and staff interviews, the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as wandering from the premises. EVIDENCE: 1. Resident 1, who was admitted to the facility on 10/26/2020, had a history and physical dated 10/20/2020 in the record. The history and physical had documentation that resident 1 has a diagnosis of Dementia, has confusion and poor short term memory. 2. The uniform assessment instruments (UAI's) completed on 10/26/2020 and again on 03/26/2021 for resident 1 had documentation that the resident is disoriented to some spheres some of the time with time, date and place being the spheres affected and that the resident requires supervision with mobility. 3. The individualized service plan (ISP) dated 10/26/2020 and again on 03/26/2021 had documentation of the residents disorientation to time, date and place and has services listed that resident 1 will be reoriented to time, date and place by the use of a clock/watch, calendar, facility literature and verbal cueing. The ISP dated 10/26/20 also had documentation under mobility that the resident requires supervision with mobility and will receive supervision from POA/RP/Family and all staff to include redirecting, cueing and prompting when outside of the community. 4. The record for resident 1 had documentation in resident notes of the resident being found on the ground outside of an adjacent facility by that facility's staff on 03/09/2021, and that that facility's staff called local EMS. Dispatch contacted this facility and informed them of resident 1's location and of the incident that had occurred. The resident notes indicated that resident 1 had expressed that she had walked outside to enjoy the weather. Resident 1 was transported to the local hospital by EMS for evaluation. 5. A phone call was received from staff person 1 on 03/30/2021 to make the LI aware of an incident pertaining to resident 1 eloping from the facility. 6. Documentation dated 03/30/2021 in progress notes explained that Resident 1 eloped from the facility and was found by a citizen of the community down on the main road (Graves Mill Road) some distance away from the facility walking towards the interstate (US Route 29). The progress notes also indicated that the citizen explained that the resident could only identify herself but not where she lived so the citizen contacted the local police who assisted in identifying where the resident resided. Documentation in the progress notes showed that resident 1 was returned to the facility by the citizen at 1:24pm. Documentation from staff person 1 signed and dated on 04/01/2021 shows that the facility reviewed video footage and determined that resident 1 left the facility through a dining room door at 11:29am 7. In reviewing the record for resident 1 and interviews with staff person 1 on 03/30/2021 it was noted that no additional measures were put in place between 3/9/2021 and 3/30/2021 to provide supervision to prevent resident 1 from wandering from the facility.
Plan of Correction:	Administrator initiated including a cognitive impairment assessment and elopement/wander risk assessment to accommodate the history and physical that is provided to the physician of any potential resident that has been diagnosed with any cognitive impairment. This documentation will be completed by physician prior to move-in to aid in decision of admission to facility. Administrator and Director of Nursing will be reassessing all residents with a diagnosis of cognitive impairment and dementia. Administrator and Director of Nursing will be auditing all UAIs and ISPs of current residents with dementia or any cognitive impairment diagnosis to include proper interventions to include alarms, staff monitoring/rounding, signage on doors, re-orientation, etc. Administrator and Director of Nursing will ensure that all ISPs reflect behavioral observations for current and future residents upon admission and as needed. Administrator requests that # 4 and # 7 of Evidence be removed due to resident not being confused during incident on 03/09/21. Resident was not confused, was able to identify information on all spheres, and did not exhibit aimless wandering and was able to identify her purpose during this incident.