Bickford of Suffolk
6860 Harbour View Boulevard
Suffolk, VA 23435
(757) 215-0058
Current Inspector: Margaret T Pittman (757) 641-0984
Inspection Date:
Complaint Related: No
- Violations:
-
Standard #: 22VAC40-73-150-C Description: Based on interviews and record review, the administrator failed to demonstrate responsibility for the general administration and management of the facility and overseeing the day-to-day operation of the facility which includes ensuring staff and volunteers comply with residents' rights.
Evidence:
1. Through interviews with floor staff, Staff #1, and Staff #2, it was determined SafelyYou video of fall events was utilized for training purposes during an all-staff meeting.
2. The SafelyYou policy for video use and documentation indicates SafelyYou services for consented residents will be accessible to authorized users which may include members of the Leadership Team.
3. The Resident Consent to Fall Detection Program for those that opt into SafelyYou services does not include consent authorizing the video documentation for general staff training.Plan of Correction: The insufficiency will be corrected as follows: Director/Health & Wellness Director will go over resident?s rights during all Staff In-Service on March 2nd, 2023. Director will ensure only direct care staff will view future SafelyYou video effective 2/14/2023.
The following measures will be taken to ensure problems do not occur again: 2/14/2023 Only direct care staff has access to view SafelyYou videos.
Persons responsible to implement and monitor corrective measure to ensure compliance: Director/Health & Wellness Director.
Standard #: 22VAC40-73-560-F Description: Based on interview, the facility failed to ensure all records are treated confidentially and that information shall be made available only when needed for care of the resident.
Evidence:
1. The facility utilizes the SafelyYou video monitoring system to identify resident health or safety risk, including fall detection and intervention for residents with cognitive impairment upon obtaining responsible party consent.
The SafelyYou policy for video use and documentation indicates ?SafelyYou video of Fall Events is considered part of the Resident?s Medical Record.?
2. The utilization of residents? medical record via SafelyYou video footage was not treated confidentially when shared as part of a general all-staff training.
3. Interviews with floor staff, Staff #1, and Staff #2 confirmed SafelyYou video of fall events was utilized for training purposes during an all-staff meeting.Plan of Correction: The insufficiency will be corrected as follows: Director will ensure any resident SafelyYou video will be viewed privately. Effective 2/14/2023.
The following measures will be taken to ensure problems do not occur again: 2/14/2023 Only direct care staff has access to view SafelyYou videos confidentially.
Persons responsible to implement and monitor corrective measure to ensure compliance: Director/ Health & Wellness Director.
Standard #: 22VAC40-73-680-B Description: Based on observation, the facility failed to ensure medications include the prescription label or direction label attached.
Evidence:
1. On 2/9/2023, the facility received a verbal order to change Resident #1?s Sertraline order from 100 mg to 150 mg. The MAR was updated to reflect this change; however, the medication on the cart (Sertraline 100 mg tablet) reads ?take 1 tablet by mouth daily.?
2. Staff #3 acknowledged the label on the Sertraline for Resident #1 does not reflect the current order.Plan of Correction: The insufficiency will be corrected as follows: Health & Wellness Director corrected the medication label on 2/14/2023.
The following measures will be taken to ensure problems do not occur again: Persons responsible to implement and monitor corrective measure to ensure compliance: Health & Wellness Director will ensure med cart audits are done on a weekly basis to ensure medication labels matches the MAR. Effective 2/14/23.
Persons responsible to implement and monitor corrective measure to ensure compliance: Health & Wellness Director.
Standard #: 22VAC40-73-680-D Description: Based on record review and interview, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber?s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing.
Evidence:
1. Resident #1?s record indicates the dosage of the resident?s Sertraline order changed from 150 mg to 100 mg on 01/14/2023; however, the MAR for Resident #1 documents the resident was administered 150 mg of Sertraline from 01/14/2023 to 02/02/2023. The MAR was adjusted on 02/02/2023 to the correct 100 mg dosage.
2. Staff #1 and Staff #2 acknowledged the MAR does not reflect the resident?s Sertraline order dosage change from 150 mg to 100 mg from 01/14/2023 to 02/02/2023, and indicates the resident received 150 mg of Sertraline during that time.Plan of Correction: The insufficiency will be corrected as follows: Health & Wellness Director corrected the MAR to match the physicians order on 2/2/2023.
The following measures will be taken to ensure problems do not occur again: Health & Wellness Director will ensure med cart audits are done on a weekly basis to ensure medication labels matches the MAR. Effective 2/14/23.
Persons responsible to implement and monitor corrective measure to ensure compliance: Health & Wellness Director.
Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.