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: Nov. 6, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Two Licensing Representatives conducted an unannounced inspection in regards to a self-report received by the facility related to alleged resident abuse on November 6, 2019 from 10:12 a.m. to 1:10 p.m. The Administrator and Director of Resident Care were present for the inspection. There were 99 residents in care. The following was discussed during the inspection: Admission paperwork, individualized service plans, resident rights, and discharge notification forms. 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 #:	22VAC40-73-310-D
Description:	Based on record review and interview, the facility failed to obtain copies of the written assurance signed by the resident or his legal representative and kept in the resident?s record. Evidence: 1. Resident #1?s copy of the written assurance in the resident?s record was not signed by the resident nor a legal representative. 2. Staff #4 and staff #5 observed and confirmed resident #1?s written assurance was not signed by the resident nor resident?s legal representative.
Plan of Correction:	Steps to correct the noncompliance with the standard Resident?s records will be audited to ensure that current resident?s records have copies of the written assurance signed by the resident or his legal representative. To be completed by 01/24/20 Measures to prevent the noncompliance from occurring again The ED/DRC/ADRC will be educated by the Regional Nurse regarding what information is required to be included in the written assurance. To be completed by 01/24/20. The ED will audit all new residents? records to ensure they contain copies of the written assurance signed by the resident or his legal representative for 2 months. To begin 1/20/20 and conclude on 3/13/19.
Standard #:	22VAC40-73-450-A
Description:	Based on record review and interview, the facility failed to ensure the resident?s preliminary individualized service plan (ISP) was signed and dated by the licensee, administrator, or his designee (i.e. the person who has developed the plan), and by the resident or his legal representative. Evidence: 1. Resident #1?s preliminary ISP was not signed and dated by licensee, administrator, or his designee, nor the resident or resident?s legal representative. 2. Staff #4 and staff #5 observed and confirmed the preliminary ISP was not signed and dated by facility staff, nor the resident or resident?s legal representative.
Plan of Correction:	Steps to correct the noncompliance with the standard Resident?s charts will be audited to ensure that current resident?s ISP is signed and dated by the licensee, administrator, or his designee, and by the resident or his legal representative. To be completed by 01/24/20 Measures to prevent the noncompliance from occurring again The ED/DRC/ADRC will be educated by the Regional Nurse to the requirement for a preliminary ISP to be completed on or within 7 days prior to admission containing appropriate information and be signed per the regulation. The ED will review all new residents? charts to ensure that a preliminary ISP was completed on or within 7 days prior to admission, contains appropriate information and signatures, weekly for 4 weeks then every other week for 4 weeks to begin 1/27/20 and be completed on 3/20/20
Standard #:	22VAC40-73-460-A
Description:	Based on record review and interview, the facility failed to assume general responsibility for the health, safety, and welfare of the residents. Evidence: 1. Staff #4 and staff #5 stated resident #1 and resident #2 moved into the facility on 10/30/19. Resident #1?s ?Nurse?s notes? dated 10/30/19 - 9:00 p.m. documented, ??Resident came to facility at 7pm with Daughter In Law. Refused all medications stating that he does not take any meds anymore. Med tech attempted three times with resident and still refused. Resident has been yelling at [resident #2] since coming to facility?? 2. Resident #1?s ?Nurse?s notes? dated 11/01/19 - 10:00 p.m. documented, ?Resident?s [resident #2] come out looking for staff stating that he would not let her into the bed. Staff went into room asking resident to please let [resident #2] get into bed. Resident stated no and started yelling and cussing out staff. Staff tried to ask resident again and resident grabbed his pocket knife out and shaked it in front of staff yelling that he wasn?t going to move over. Staff tried to move residents leg over a little bit so [resident #2] can get into bed and resident tries to take staff pictures. [Resident #2] finally got into bed 30 minutes later. Supervisor already made aware of situation. Staff will monitor of any issues.? 3. Staff #1 and staff #2 stated during interview that on 11/03/19, staff #2 went to resident #1 and resident #2s? room to offer meals, as it was reported that ?neither resident had come out of their room on that date?. Staff #2 stated that resident #1 allegedly stated that both residents were not hungry; however, staff #2 stated that he asked resident #2 directly whether she was hungry, to which the resident responded ?yes.? Staff #1 and staff #2 stated that resident #1 was not allowing resident #2 to eat. 4. Staff #1 stated resident #2 approached a staff member on 11/05/19 and stated resident #1 had ?kicked her?. Staff #1 and staff #2 reported speaking to resident #2 privately who expressed that resident #1 had been abusive. Staff #2 stated resident #2 stated ?[Resident #1?s name] hit me.? 5. An incident report received on 11/05/19 by the regional licensing office documented, ?Around 6:30 am today, 11/05/2019, one of our residents, [resident #2?s name], was found in the hallway complaining of stomach pain and said that her husband, [resident #1?s name], had kicked her in the stomach.? Resident #2 was taken to [Hospital name] on 11/05/19 due to ?alleged abuse? that took place on that date. Staff #4 and staff #5 stated, ?[Resident #2] did have abdominal bruising consistent with the injury reported.? The diagnoses from hospital discharge paperwork on 11/05/19 documented ?contusion to the abdominal wall, assault, and acute cystitis without hematuria.? 6. Staff #4 and staff #5 stated during interview that two knives were confiscated from resident #1 due to the facility?s weapons policy. 7. Staff #4 and staff #5 confirmed that the health, safety, and welfare of resident #2 was affected and that resident #2 sustained an injury as a result.
Plan of Correction:	Steps to correct the noncompliance with the standard The ED/DRC will be re-educated to recognizing and reporting resident abuse or neglect by the RDH by 1/24/20. Measures to prevent the noncompliance from occurring again DRC/Designee will conduct an in-service with all LPNs, CNAs and Medication Aides on Recognizing & Reporting Resident Abuse or Neglect. To be completed by 1/31/2020. Current staff will be re-educated to recognizing and reporting resident abuse or neglect by the ED/designee by 1/31/2020. Going forward, training regarding recognizing and reporting resident abuse or neglect will occur during orientation, annually and as needed.