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: Jan. 29, 2021 , Feb. 9, 2021 , Feb. 10, 2021 and Feb. 12, 2021

Complaint Related: Yes

Areas Reviewed:

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 January 29, 2021 and concluded on February 12, 2021. A complaint was received by the department regarding allegations in the areas of medication administration and physician/prescribers orders. 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 evidence gathered during the investigation supported the allegations of non-compliance with standards or law, and violations were issued.

Violations:

Standard #:	22VAC40-73-650-A
Complaint related:	Yes
Description:	Based on record review and discussion, the facility failed to ensure no medication, or medical procedure, was changed, or discontinued by the facility without a valid order. Evidence: 1. Resident #1 physician or other prescriber?s orders were changed and/or discontinued: A. Prescriber order documented, ?Hold Januvia until further notice starting 9/25/20, check glucose Mon, Wed, and Fri until 10/16/20 once daily?. October 2020 MAR documented Januvia was administered on 10-01-2020. Staff #1 did not provide September 2020 MAR requested during the inspection. B. Trazodone order was discontinued on 11-17-2020, however; December 2020 MAR documented it was administered on 12-02-2020; C. December 2020 MAR documented resident?s Blood pressure (BP) monitoring was ?d/ced? [discontinued] by Staff #6; however, Staff #1 could not provide an order. BP monitoring was not documented for the month of October 2020, 10 times in November 2020, 4 times in December 2020 and 6 times in January 2021. Order to discontinue BP monitoring was not provided by Staff #1. 2. Staff #1 confirmed the aforementioned and could not provide additional documentation.
Plan of Correction:	1. Resident 1?s medications are no longer changed or discontinued by the Community without a valid order. 2. Wellness Director educated staff on monthly MAR turnover and verifying, then transcribing previous months medications onto new month?s MARs. The Wellness Director corrected the order per the physician?s order. 3. The Waterford transitioned to the EMAR system on 3/8/21 and RMAs will not transcribe onto paper MAR. Monthly paper MAR will not be used. The EMAR system will flag new orders entered by the pharmacy to alert the Wellness & Assistant Wellness Director to verify them for accuracy and approval daily. 4. The Wellness Director or designee will be responsible for implementing and or monitoring preventive measures.
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on record review and discussion, the facility failed to ensure medications were administered in accordance with the physician's instructions. Evidence: 1. Resident #1?s Nursing Notes dated 12-02-2020 documented, ?NP [Nurse Practitioner] came to community to see resident? Reviewed MAR [Medication Administration Record] upset that medications on new MAR were not accurate. Writer reviewed MAR + corrected Metformin, Lexapro + Zyprexa. Resident missed dose.? The note was signed by Staff #2. 2. Resident #1?s November 2020, December 2020 and January 2021 MARs documented the following: A. Zyprexa 2.5 mg was ordered 11-17-2020 however was not administered 11-17-2020 through 11-25-2020 and 12-02-2020. B. Metformin 1500 mg was ordered 11-12-2020, however; Metformin 1000 mg. was administered; C. Physician?s orders dated 11-17-2020 documented, ?Start Lexapro 15 mg ((1) 10 mg tab + (1) 5 mg tab) [sum total of 15 mg.] q am [every morning] PO [by mouth]?; however, Lexapro 10 mg was administered 01-01-2021, 12-01-2020 and 12-02-2020, 01-02-2021, in addition to 15 mg administered on the same dates. D. Staff #1 confirmed the aforementioned medications were not administered in accordance with the physician?s instructions, and could not provide explanations.
Plan of Correction:	1. Resident 1?s medications being administered in accordance with the physician?s instructions. 2. The Wellness Director educated RMAs on verifying medication orders and second checks to be completed by a second RMA to verify accuracy. The Wellness Director corrected orders on the MAR per the physician orders. The community transitioned from using paper Medication Administration Records (MAR) to using an EMAR system on March 8, 2021. Physician orders will be faxed to our pharmacy, the pharmacy will enter the physician?s orders into the EMAR system. The system will flag the newly entered orders to alert the Wellness & Assistant Wellness Director to verify them for accuracy and approval daily. Once verified & approved, the new orders will populate into the system. 3. The Wellness Director or designee will be responsible for implementing and or monitoring preventive measures.
Standard #:	22VAC40-73-680-I
Complaint related:	Yes
Description:	Based on record review and discussion, the facility failed to ensure the Medication Administration Record (MAR) included the initials of direct care staff administering the medications. Evidence: 1. January 2021 MARs did not contain the initials of staff who administered medications: A. Resident #1 - 32 times to include Glipizide, Amlodipine Besylate, Losartan, Memantine; B. Resident #2 - 15 times to include Memantine, Ferrous Sulfate, Tamsulosin, Sertraline; and C. Resident #3 - 23 times to include Famotidine, Lexapro, Dicyclomine, and Levothyroxine Sodium. 2. Staff #1 confirmed initials of direct care staff were not documented on the aforementioned MARs.
Plan of Correction:	1. Residents 1, 2 and 3 MARs will include the initials of direct care staff administering their medications. 2. Wellness Director educated staff on importance of writing their initials on MAR after administering medications to each resident. New EMAR system will alert RMA of medications that were not signed off. Wellness Director and Assistant Wellness Director will review the medication variance report daily. 3. The Wellness Director or designee will be responsible for implementing and or monitoring preventive measures.