VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Village at Orchard Ridge
400 Clocktower Ridge Drive
Winchester, VA 22603
(540) 431-2800

Current Inspector: Jill James (540) 418-2631

Inspection Date: June 15, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical Assistance:

Discussed the importance of conducting monthly audits of the electronic medication administration records and having specific protocols to ensure all medication orders are entered accurately within 24 hours using the correct processes.

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/15/2022 from approximately 10:35 am to 5:10 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 4/14/2022 regarding allegations in the areas of medication administration and documentation. Number of residents present at the facility at the beginning of the inspection: 14 Number of resident records reviewed: 3 (selected sections) Number of staff records reviewed: 3 (selected sections) Number of interviews conducted with staff: 6 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Janice Knight, Licensing Inspector at (540) 430-9258 or by email at Janice.knight@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-640-A
Description:	Based upon documentation and interviews, the facility failed to ensure implementation of the medication management plan by reviewing a changed medication order within 24 hours of receipt to ensure accurate transcription and to conduct monthly reviews of the electronic medication administration records (eMARs) for one of three resident records reviewed. Evidence: 1. Resident 1 had a physician?s order signed 1/31/2022 to, ?Decrease Eliquis to 2.5 mg BID for GIB.? 2. The February, March and April (through 4/12/2022) eMARs did not include this new order. 3. On 6/15/2022, the licensing inspector (LI) interviewed staff 1 who stated staff 2 entered the information; however, she clicked the wrong button when entering the order and it was not added to the eMAR. Staff 1 also stated staff 2 was the nurse on duty who was supposed to check the order within 24 hours to ensure it was entered correctly and since she was the one who entered the information she did not conduct the second check. 4. On 6/21/2022, the LI conducted a telephone interview with staff 2, night shift charge nurse, and she stated, ?I didn?t put the order under pharmacy but I put it under other. I was aware of the correct way to enter it but I made a mistake. I guess I wasn?t thinking and I didn?t recheck it within 24 hours since I was the one who entered the order.? 5. The section of the medication management plan titled ?Physician Order Accuracy Assurance? states, ?All physician orders will be double checked by the night shift charge nurse/med tech for accuracy and proper documentation within 24 hours of receipt of a new order or change in order.? 6. The section of the medication management plan titled ?Medication Management Policy, Policy Interpretation and Implementation? states, ?Regular audits by DON or designee to monitor medication administration and the effective use of the electronic medication administration record (eMAR) documentation: this process includes checking medication orders to ensure accuracy and request discontinuation of unnecessary medication to physician. Medication orders will be reviewed in electronic medical record monthly by DON or designee, then printed for physician to review and signed.?
Plan of Correction:	Resident 1 was seen and examined by nurse practitioner on 4/19/2022 and Eliquis was resumed. A cardiologist appointment was also scheduled and resident was seen by her cardiologist on 5/16/2022. Resident 1?s record was reviewed, and no similar error was identified. Other residents? records were reviewed, no similar error was identified. Monthly orders, eMARs, and electronic treatment administration records (eTARs) reviews will be completed by director of nursing (DON), assisted living (AL) manager, or designee. Day shift nurses will check orders entered by night shift nurses. Education on medication order entry will be provided to nurses, and certified medication aides (CMAs) by DON, AL manager or designee.
Standard #:	22VAC40-73-680-D
Description:	Based upon documentation, the facility failed to ensure one medication each for two of three residents? were administered as ordered. Evidence: 1. Resident 1 had a physician?s order signed 1/31/2022 to ?Decrease eliquis to 2.5 mg BID day for GIB.? 2. The eMARs for February, March and April (through 4/12/2022) did not include this new order and the medication was not administered. 3. On 6/15/2022, the LI interviewed staff 1 who stated this medication was not administered as it did not show up on the eMAR because the nurse did not follow the proper order entry process. 4. Resident 3 had an order signed 6/9/2022 for ?Norvasc 10 mg by mouth in the morning for Hypertension Hold if Systolic is less than 130.? 5. On 6/6/2022 blood pressure was documented as 126/84; on 6/7/2022 as 128/84 and on 6/14/2022 as 128/74. The eMAR was initialed by staff 3 as medication administered on these three days.
Plan of Correction:	Resident 1 was seen and examined by nurse practitioner on 4/19/2022 and Eliquis was resumed. A cardiologist appointment was also scheduled, and resident was seen by her cardiologist on 5/16/2022. Resident 1?s record was reviewed, and no similar error was identified. Other residents? records were reviewed, no similar error was identified. Monthly orders, eMARs, and eTARs reviews will be completed by DON, AL Manager, or designee. Day shift nurses will check orders entered by night shift nurses. Education will be provided to nurses, CMAs by DON, AL manager or designee, on medication order entry. Education will be provided to nurses, and CMAs by DON, AL manager or designee to follow blood pressure perimeters as indicated in physician orders. Routine, and random med pass observations to be completed by DON, AL manager or designee
Standard #:	22VAC40-73-680-I
Description:	Based upon documentation and an interview, the facility failed to ensure all required information was documented in the eMARs for three of three resident records reviewed. Evidence: 1. The eMAR for resident 1 was blank for weight on 5/4/2022 and 5/27/2022. 2. The eMAR for resident 2 was blank for Atorvastatin Calcium at 6:00 pm on 6/7/2022 and for cleansing the fourth toe on right foot on the 7:00 am to 7:00 pm shift on 6/7/2022 and 6/11/2022. 3. The eMAR for resident 3 was blank on 6/7/2022 at 5:00 pm for Preservision AREDS and Refresh Tears. 4. On 6/15/2022, the LI interviewed staff 3 who stated she failed to go back and initial the eMARs once the treatments/medications were administered.
Plan of Correction:	Resident records were reviewed. Nurses/CMAs involved will receive coaching and education to address blank eMARs. and documented coaching/corrective action will be entered in their files. Each nurse/CMA will pull a medication/treatment administration report at the end of each shift to verify and confirm that all due treatments/medications have been administered. The report will be submitted to the DON, AL manager, or designee. DON, AL manager or designee will review shift medication/treatment administration report submitted by staff.