VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Waterford at Virginia Beach
5417 Wesleyan Drive
Virginia beach, VA 23455
(757) 490-6672

Current Inspector: Lanesha Allen (757) 715-1499

Inspection Date: Sept. 29, 2020 , Sept. 30, 2020 , Oct. 22, 2020 and Oct. 23, 2020

Complaint Related: Yes

Areas Reviewed:

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

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on 09-29-2020 and concluded on 10-23-2020. A complaint was received by the department regarding allegations in the areas of Infection Control Program and Direct Care Staff Training. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-325-C
Complaint related:	No
Description:	Based on resident records reviewed and interview, the facility failed to document interventions that were initiated to prevent or reduce risk of subsequent falls when a resident who meets the criteria for assisted living care falls. Evidence: 1. Resident #1?s current Uniform Assessment Instrument dated 05-06-2020 documented the resident meets criteria for assisted living care. 2. The ?Nurses Notes? documented resident #1 had a fall on 10-02-2020 ?reopening a wound on forehead,? and on 10-04-2020 with a ?laceration to the center of head (back).? 3. ?Fall Risk Rating? forms were completed for resident #1?s falls on 10-02-2020 and 10-04-2020; however, the forms did not include interventions that were initiated to prevent or reduce risk of subsequent falls. 4. Resident #1?s current Individualized Service Plan (ISP) dated 05-06-2020 documented the resident is a fall risk; however, the ISP was not updated to include interventions to prevent or reduce risk of subsequent falls after resident #1 sustained the falls on 10-02-2020 and 10-04-2020. In addition, resident #1 had a physician?s order dated 08-28-2020 which documented ?Protective Helmet as tolerated (hx: falls);? however, the protective helmet was not identified on the resident?s ISP. 5. Staff #1 could not provide documentation of interventions that were initiated after each of resident #1?s aforementioned falls.
Plan of Correction:	1. Resident 1?s Uniform Assessment Instrument (UAI) was updated to document interventions that were initiated to prevent or reduce risk of subsequent falls when a resident who meets the criteria for assisted living care falls. 2. The RMA?s will be in-serviced on documenting interventions that were initiated to prevent or reduce risk of subsequent falls when a resident who meets the criteria for assisted living care falls. In addition, the RMAs will be trained on the fall management handbook, which includes the falls management intervention form. The Assistant Wellness Director will ensure that intervention form is in place after each fall. 3. The Assistant Wellness Director or designee will be responsible for ensuring that interventions that were initiated to prevent or reduce risk of subsequent falls when a resident who meets the criteria for assisted living care falls are documented.
Standard #:	22VAC40-73-650-F
Complaint related:	No
Description:	Based on record review and interview, the facility failed to ensure whenever a resident is admitted to a hospital for treatment of any condition, the facility should obtain new orders for all medications prior to or at the time of the resident?s return to the facility. The facility should ensure the resident?s primary physician is made aware of all medication orders and has documented any contact with the physician regarding the new orders. Evidence: 1. Resident #1?s hospital ?Discharge Summary Notes? dated 10-02-2020 documented the resident was admitted to the hospital on 09-28-2020 and discharged back to the facility on 10-02-2020. The summary notes documented an ?Admission Diagnosis? of a ?UTI (urinary tract infection), fall, and frequent falls.? The summary notes also documented to start taking ?Nitrofurantoin monohydrate macro (Macrobid) 100mg PO Caps- Take 1 cap by mouth twice daily for 10 days.? 2. Staff #1 could not provide documentation of any contact made by staff to resident #1?s primary physician regarding the new hospital medication order prior to or at the time of the resident?s return to the facility. 3. Resident #1?s October 2020 Medication Administration Record (MAR) documented the first dose of Nitrofurantoin 100mg was administered by staff on 10-12-2020; which was 10 days after the resident returned to the facility. The MAR did not document that staff administered Nitrofurantoin 100mg to resident #1 on 10-02-2020 through 10-11-2020. 4. Staff #1 acknowledged resident #1?s primary physician was not made aware of the new aforementioned medication orders. Staff #1 also acknowledged the facility did not obtain new orders for the Nitrofurantoin 100mg prior to or at the time of the resident?s return to the facility.
Plan of Correction:	1. Staff were in-serviced if a resident is admitted to a hospital for treatment of any condition, the Community will obtain new orders for all medications prior to or at the time of the resident?s return to the Community. In addition, staff will ensure that the resident?s primary physician is made aware of all medication orders and will documented any contact with the physician regarding the new orders. 2. Staff were in-serviced if a resident is admitted to a hospital for treatment of any condition, the Community will obtain new orders for all medications prior to or at the time of the resident?s return to the Community. In addition, staff will ensure that the resident?s primary physician is made aware of all medication orders and will documented any contact with the physician regarding the new orders. 3. The Assisted Wellness Director, Wellness Director or designee will be responsible for ensuring that when a resident is admitted to a hospital for treatment of any condition, the Community obtains new orders for all medications prior to or at the time of the resident?s return to the Community. In addition, the Assisted Wellness Director, Wellness Director or designee will be responsible for ensuring that the resident?s primary physician is made aware of all medication orders and that such contact with the physician regarding the new orders is documented.