VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Vitality Living West End Richmond
1800 Gaskins Road
Henrico, VA 23238
(804) 741-8880

Current Inspector: Kimberly Davis (804) 662-7578

Inspection Date: Oct. 26, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

A non-mandated self-report inspection was initiated on October 22, 2021 and concluded on November 3, 2021. A self-reported incident was received by the department regarding allegations in the areas of resident care and related services. The Executive Director was contacted by telephone to conduct the investigation. The licensing inspector emailed the Executive Director a list of documentation required to complete the investigation. The licensing inspector conducted an on-site observation at the facility on October 26, 2021. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and violations were issued.

Violations:

Standard #:	22VAC40-73-640-A
Description:	Based on record review and interview with staff, the facility failed to ensure the facility?s medication management plan was implemented including methods to ensure that each resident's prescription medications ordered for the resident are filled in a timely manner to avoid missed dosages, and methods for verifying that medication orders have been accurately transcribed to medication administration records (MARs) within 24 hours of receipt of a new order or change in an order. Evidence: 1. A self-reported incident received from the facility by the regional licensing office on 10-07-2021 documented the following, ?Resident [#1] was ordered acetaminophen-hydrocodone 325 mg 7.5 mg tab 1tab by mouth twice a day x10 days. Faxed to pharmacy 10/4/2021 medication was noted 10/6/2021 that medication wasn?t in community. Pharmacy stated medication was sent to community on 10/4/2021 at night?.? 2. Physician #1?s letter to the pharmacy dated 10-07-2021 documented Resident #1?s order for acetaminophen-hydrocodone was ordered and faxed to the facility on 10-01-2021. 3. The facility?s medication management plan regarding ordering and receiving medication documented, ?It should be expected that medication will be delivered to community within 24 hours after new order is sent to pharmacy by community. If it is not, pharmacy should be immediately contacted so that medication can be received.? 4. The incident report dated 10-07-2021 documented, ??Medication Aide [Staff #2] signed for the medications on 10/4/21 from the pharmacy driver? medication was received and left in bag in nursing office? told 7-3 shift on 10/5/2021 medication aide [Staff #3] to put medication away??. Additionally, Staff #4 made a late entry note on 10-07-2021 that documented, ?Late Entry: On 10/4/2021 orders were faxed to pharmacy acetaminophen-hydrocodone 325mg 7.5 mg PO tab 1tab PO BID X10 days? per [Nurse Practitioner #1] orders faxed?? 5. Staff #1 confirmed Resident #1?s order for acetaminophen-hydrocodone 325 mg 7.5 mg was not filled in a timely manner after receiving the order to avoid missed dosages. Additionally, the pharmacy was not contacted when the medication was not discovered within 24 hours. 6. Resident #1?s order for acetaminophen-hydrocodone 325 mg 7.5 mg tab 1tab by mouth twice a day x10 days was dated 10-01-2021 and signed by Nurse Practitioner #1; however, the Shift Report documented the new order was received 10-04-2021. 7. Resident #1?s October 2021 MAR documented the effective date for acetaminophen-hydrocodone as 10-04-2021. 8. The facility failed to ensure Resident #1?s medication was transcribed to the October MAR within 24 hours of receipt of the new order.
Plan of Correction:	After the community self-reported the incident, we moved forward with an in-service on proper processing of ordering and receiving medications from the pharmacy. We coordinated with the pharmacy to adjust the process for medication delivery moving forward.
Standard #:	22VAC40-73-680-D
Description:	Based on record review and interview with staff, the facility failed to ensure medications were administered in accordance with the physician?s instructions. Evidence: 1. Resident #?s acetaminophen-hydrocodone 325 mg was ordered on 10-01-2021 according to Physician #1?s note to the pharmacy on 10-07-2021. Resident #1 did not receive the medication for five days (10-02-2021 to 10-06-2021) totaling 10 doses, according to the October Medication Administration Record (MAR). The October MAR documented the following: a. 10-04-2021 8PM: ?Med not available ? awaiting pharmacy delivery? b. 10-05-2021 7:30AM: ?Med was not in MAR OR CART at this scheduled time? c. 10-06-2021 7:30AM: ?Med not available ? awaiting pharmacy delivery?, 10-06-2021 8PM ?Med not available ? awaiting pharmacy delivery.? 2. Staff #1 acknowledged that Resident #1 did not receive the prescribed medication as instructed from 10-02-2021 through 10-06-2021.
Plan of Correction:	Inservice was completed with nursing staff instructing them to check at start of the shift to see if there are any new medication orders to be reviewed. Frequent med cart audits are being completed by the assigned team member in house, as well as quarterly audits by Southern Pharmacy.