VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Tidewater Cove, Operated by Western Tidewater CSB
2536 East Washington Street
Suffolk, VA 23434
(757) 935-1415

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: Jan. 31, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

An unannounced focused monitoring inspection was conducted on January 31, 2020 from 10:00 am until 4:03 pm. There were 63 residents in care. During the inspection, resident records were reviewed. Residents and staff were interviewed. A review of the medication cart and medication room was conducted. The facility's documentation of medications received from the pharmacy. A discussion was held regarding medication administration, supervision of residents, and location and contents of the facility's stat-box. Areas of non-compliance were reviewed with the Administrator throughout the inspection and during the exit interview. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice. The plan of correction must indicate how the violation will be or has been corrected. Your plan of correction should include: 1. Step(s) to correct the non-compliance with the standard(s) 2. Measures to prevent re-occurrence 3. Person(s) responsible for implementing each step and/or monitoring any preventive actions. The plan of correction is due within 10 calendar days.

Violations:

Standard #:	22VAC40-73-680-N
Description:	Based on interviews and review of the facility's stat-drug box, the facility failed to ensure the medications from the stat-drug box were only removed by a nurse with an order from the prescriber. Evidence: 1.Interviews with staff #1 and staff #2 revealed the stat-box was delivered to the facility on 1-14-20 and contained Vicatin, Xanax, and Azythromycin. On 1-20-2020 five (5) Vicatin 325mg tabs, five (5) Xanax 0.25mg tabs , and one (1) pack of Azythromycin 250mg containing six (6) tabs were identified as missing from the facility's stat-drug box by the pharmacy. The facility's "Stat Box Sign Out Sheets" did not document the Vicatin, Xanax, and Azythromycin were removed from the stat box by a nurse and there was no physician?s order for the medications. 2.During interview staff #1, #2 and #3 acknowledged the facility did not receive orders for Vicatin, Xanax, or Azythromycin from 1-14-2020 through 1-17-2020. Staff were unable to verify that the stat box was opened by a nurse and were unable to identify who retrieved the medications from the stat box.
Plan of Correction:	A full investigation was done no one to include pharmacy or Tidewater Cove could pinpoint the day the medications were removed from the Stat Box. A decision was made by the administrator to permanently remove the STAT BOX from the facility on the evening of January 31, 2020. The facility will use Walgreens who is the backup pharmacy assigned to us by Jones Pharmacy. If any medications are needed after hours or on the weekend, staff will have to go to the pharmacy.