VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Jefferson
900 North Taylor Street
Arlington, VA 22203
(703) 516-9455

Current Inspector: Alexandra Roberts (804) 845-6956

Inspection Date: Jan. 27, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

An unannounced focused-monitoring inspection was conducted on 1/27/20, to follow-up on high-risk violations that were cited on 11/14/19. Medication administration was observed and physician's orders were reviewed. The violation was discussed and an exit meeting was held. Areas of non-compliance are identified on the violation notice. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word 'corrected' is not acceptable. The 'plan of correction' must contain: 1) Steps to correct the non-compliance with the standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. Thank you for your cooperation and if you have any questions, please contact me via e-mail at m.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-680-D
Description:	Based on observation and record review, the facility failed to ensure that medications are administered in accordance with the physician's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Evidence: Resident #1's morning medication administration was observed during the inspection. The resident's medications were placed in a pill cup and the medication packages were returned to the medication cart. Resident #1's pulse (84) and blood pressure (91/52) were taken before her medication was administered. Resident #1 asked for applesauce along with her medications. Facility staff returned to the medication cart for the applesauce. Before the applesauce could be added to the pill cup, the licensing inspector inquired about Resident #1's lisinopril, as the tablet had not been removed from the pill cup. The order for Resident #1's lisinopril, dated 12/30/19, calls for the medication to be held if Systolic Blood Pressure (SBP) is less than 100 or the resident's pulse is less than 60. The Medicaiton Administration Record (MAR) indicated that the medication was also administered on 1/7/20, when the resident's blood pressure was 99/58. The morning medication administration was observed for Resident #2. Resident #2's medications were placed in a pill cup and the medication packages were then returned to the medication cart. Before the medication was administered, the licensing inspector asked about Resident #2's Senna-Docusate. The pill cup only contained one tablet of Senna-Docusate. Resident #2's order for Senna-Docusate, dated 1/7/20, called for the resident to receive two tablets during the medication administration.
Plan of Correction:	Upon identification, Resident #1 and Resident #2 received their medications in accordance with the physician?s instructions at the time of the survey. Staff member #1 who administered the morning medications for Resident #1 and Resident #2 was given refresher training by the Resident Care Director regarding administering medications in accordance with physician orders, including a focus on conducting a triple check of medications to EMAR prior to administration. An unannounced medication pass observation was conducted with Staff member #1 later the same day by the Resident Care Director and additional in-the-moment education was provided. Unannounced medication pass observations will be conducted on the various shifts with RMAs and LPNs responsible for medication administration by Resident Care Director or designee over the next 2 weeks to validate that they are administering medications in accordance with physician orders. If incorrect practice is observed, on-the-spot training will be provided and additional observations will be conducted to validate correct practice. Unannounced medication pass observations will be conducted with RMAs and LPNs responsible for medication administration by the Resident Care Director or designee weekly for the next three months to validate that they are administering medications in accordance with physician orders. In-the-moment coaching will be provided as needed. In addition, RMAs and LPNs will be observed by the RCD or designee on shifts they do not usually work. If continued incorrect practice is observed, the staff member will removed from the assignment and placed back on orientation until consistent correct medication administration practice can be confirmed by the RCD. The results of these monthly med pass observations will be reviewed at Quality Assurance / Performance Improvement meetings. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary actions or extend the review period. The Executive Director and/or Administrator are responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.