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: Feb. 15, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 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:

The LI for Bentley Commons began a self reported incident investigation on 02/15/2022. An email was sent to the facility Administrator on 02/15/2022 requesting resident record and documentation information to be sent tot he LI. A on-site follow up visit was conducted on 04/14/2022. A tour of the facility physical plant was conducted and interviews were held with staff. An exit interview was conducted with the facility Administrator on the day of the on-site inspection in which all violations were discussed and opportunities were given for the facility to provide any additional information. Please respond back to your LI with your plan of correction within 10 days of receipt of this notice. If you have any questions or concerns please feel free to contact your LI at 540-309-2968.

Violations:

Standard #:	22VAC40-73-450-H
Description:	Based on a review of resident records, facility documentation and interviews with staff, the facility failed to ensure that services specified in a residents individualized service plan (ISP) was provided. EVIDENCE: 1. The uniform assessment instrument (UAI) dated 01/13/2022 in the record for resident 1 has documentation that the resident is disoriented to some spheres some of the time with time, place and situation being the spheres affected. The UAI also has documentation that resident 1 requires mechanical and human help supervision with mobility. 2. The ISP dated 01/13/2022 in the record for resident 1 has documentation that the resident is disoriented to time, place and situation some of the time and is to be redirected/reoriented by staff as needed. The ISP also has documentation that resident 1 requires mechanical and supervision with mobility to go outside of the community. 3. A facility self reported incident was received by the LI on 02/12/2022. The incident report has documentation that on 02/11/2022 resident 1 " stated to the concierge at 5:55pm that she was going to sit on the front porch. Concierge states she does this most evening after dinner and that concierge "peaks in on her every few minutes while outside". The concierge went to check on her after 5minutesand saw her in the parking lot walking towards another building. Concierge immediately walked over to her and asked her where she was going. Resident stated she was going to her room. The concierge then re-directed her and brought her inside and immediately called the Executive Director at 6:06pm once resident was safely inside." The record for resident 1 does not have documentation that the supervision required for resident 1's mobility outside of the community was continuously provided while resident 1 was sitting outside on the front porch.
Plan of Correction:	ED self-reported this incident to licensing after concierge stated to ED that the resident went outside to sit on the porch with another resident. After five minutes concierge checked on this resident to find her in the parking lot. Resident was immediately brought inside, ED and POA was immediately called, and 24/7 sitters were put in place. Resident was discharged to a secure unit four days later. ED coached staff and concierge regarding residents that have supervision checked on their UAI for mobility and how staff must always supervise these residents while out of the facility. The resident binder will be updated to include all residents that are not permitted to sit on the porch unattended, per their UAI/ ISP. This will be left at the concierge desk. ED/ DON will in-service staff regarding the meaning of mobility and supervision as it pertains to our residents. Completed by 5/4/2022