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: March 22, 2021 , March 24, 2021 and March 30, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 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 March 22, 2021 and concluded on March 30, 2021. A complaint was received by the department regarding allegations in the areas of medication administration. 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. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-300-B
Complaint related:	No
Description:	Based on record review and discussion, the facility failed to ensure a method of written communication was utilized as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents. A record shall be kept of the written communication for at least the past two years. Evidence: 1. ?Shift-to-shift? notes requested for January 2021 were requested to be provided during inspection. 2. Staff #1 and staff #2 confirmed the notes were not available and are purged after 30 days.
Plan of Correction:	1. Shift-to-shift notes will be retained for 2 years. 2. The Executive Director will update the policy pertaining to the Shift-to-Shift Report Record will be revised to reflect the required 2-year retention in accordance with Virginia?s Assisted Living Standards. 3. The Executive Director --or designee will ensure the Shift-to-Shift Report Record are being retained for 2 years.
Standard #:	22VAC40-73-560-H
Complaint related:	No
Description:	Based on record review and discussion, the facility failed to ensure the complete resident record was retained for at least two years after the resident leaves the facility. Evidence: 1. Resident #1 discharged from the facility on 02-18-2021. The record did not contain Resident #1?s nursing notes that were originally in the record as confirmed by Staff #1. 2. Staff #1 and staff #2 confirmed that Resident #2?s nursing notes were not retained in the record and were not made available after the resident had left the facility.
Plan of Correction:	1. Resident 1 is no longer in the Community. 2. The Community will retain a complete resident record for 2 years after the resident leaves the Community. In addition, the Wellness Director, Assistant Wellness Director, or designee will initiate a double-check of former resident?s full record to ensure they are retained for at least 2 years. 3. Executive Director or designee will do random audits to ensure documented incidents remain in the chart.
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 prescriber's instructions. Evidence: 1. An email received on 01-21-2021 documented, ?I wanted to inform you of a medication error? [Resident #1] - The order was written on 1/8/21 and the error was caught today 1/21. Correct order: Divalproex 125mg 1 by mouth every day Seroquel 12.5mg 1 by mouth every day The RMA [Registered Medication Aide] wrote the order as: Divalproex 125mg 1 by mouth three times a day Seroquel 12.5mg 1 by mouth three times a day?? 2. Prescriber?s orders dated 01-07-2021 documented, ?start Divalproex 125 mg one tab PO QD start Seroquel 12.5 mg one tab PO QD?. 3. Resident #1?s Progress Notes signed by the prescriber on 01-24-2021 documented, ?DON [Director of Nursing] reports error occurred when staff transcribed medication order to MAR [Medication Administration Record] for Seroquel and Valproic Acid [Divalproex]. Was transcribed as Seroquel mg one tab PO [by mouth] TID [three times daily] and Valproic Avid 125 mg one tab PO TID. Error was corrected 1/20/21? Wife reports patient has been sleeping 10+ hours at night and napping during the day over the last week. Explained to them that it is likely due to the increased Seroquel dose?? 4. Staff #3 when asked why transcribed incorrectly could not recall the reason why or cause for transcription error. Staff #3 did not deny the error. 5. Staff #1 and staff #2 confirmed during interview that Resident #1?s prescriber?s orders for the aforementioned medications was administered incorrectly for 13 days.
Plan of Correction:	1. Resident 1?s medication is being administered in accordance with the prescribers? instructions. 2. On March 8, 2021, the community transitioned from using paper Medication Administration Record (MAR) to using an EMAR system. Physician orders will be faxed to our pharmacy, the pharmacy will enter the physicians? orders into the EMAR system. The system will flag the newly entered orders to alert the Wellness Director and 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 monitoring the preventive measures to ensure compliance.