VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Gardens of Virginia Beach
5620 Wesleyan Drive
Virginia beach, VA 23455
(757) 499-4800

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: Dec. 11, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

A Licensing Representative conducted an unannounced monitoring inspection on December 11, 2019 from 9:34 a.m. to 12:37 p.m. due to an IPOC received. There were 99 residents in care. The Executive Director and Director of Resident Care were present throughout the inspection. The following was discussed during inspection: ensuring internal auditing forms are filled out accurately and completely, medication administration, and the importance of familiarizing all staff with regulations. Please submit your ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it within 10 calendar days. The plan of correction must indicate how the violation will be or has been corrected. The plan of correction must include: 1. Step(s) to correct the noncompliance with the standard(s) 2. Measures to prevent reoccurrence 3. Person(s) responsible for implementing each step and/or monitoring any preventative measures. If you have any questions, please contact your inspector Alexandra Poulter at 757-613-5133 or alexandra.poulter@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-640-A
Description:	Based on record review, observation, and interview, the facility failed to adhere to the medication management plan regarding methods to ensure that each resident's prescription medications were ordered for the resident and refilled in a timely manner to avoid missed dosages. Evidence: 1. During a medication administration observation conducted by staff #1 (Cart 1), resident #1 was not administered Lisinopril 40 mg tablet, once daily, scheduled for 10:00 a.m. Staff #1 stated the medication had run out. 2. Resident #1?s December 2019 Medication Administration Record (MAR) documented Lisinopril 40 mg was not administered on 12-10-19 or 12-11-19. 3. The facility?s medication management plan documented methods to ensure that each resident?s prescription medications are refilled in a timely manner to avoid missed dosages as follows: ?Refills will be ordered when there is 5 days of medication left for non-cycle fill communities. Nurse or medication aide will pull the reorder sticker and fax it to the pharmacy. For private medication supplies, per the signed resident agreement, the family is contacted when there is 10 days of medication left. Documentation will be made in the 24-hour log. The family will be re-contacted if the medications are not received within 5 days of notification for refill and informed that the medication will be ordered from [Pharmacy name] if medication is not received within 24 hours?? 4. Staff #2 and staff #3 observed and confirmed resident #2 did not receive the aforementioned medication for two days due to the medication not being ordered per the facility?s medication management plan.
Plan of Correction:	Steps to correct the noncompliance with the standard Medication carts will be audited to ensure that current residents medication is available and in the cart. Medications will be re-ordered as appropriate, to be completed by 1/17/20 Measures to prevent the noncompliance from occurring again DRC//Designee will conduct an in-service with all LPNs and Medication Aides on the medication management plan to ensure a understanding of proper ordering and refilling of prescription medications in a timely manner to avoid missed dosages. To be completed by 1/24/2020. DRC/designee will audit medication carts 3 times a week for 4 weeks then weekly for 4 weeks to ensure all medication is available. To begin 1/20/20 and conclude on 3/13/19. The DRC will share the outcomes of all audits with the ED. ED is responsible for overall POC completion, monitoring and follow up.