VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Heritage Green Assisted Living Communities
201 & 202 Lillian Lane
Lynchburg, VA 24502
(434) 385-5102

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: March 23, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

The LI for Heritage Green Assisted Living conducted an unannounced focused monitoring visit via phone on 03/23/2020 to follow up on a facility reported incident that was received by the licensing office on 02/29/2020. The LI reviewed requested information that included two resident medication administration records (MARs), controlled substance count records, the facility?s current medication management policy and conducted a phone interview with staff relating to a self-report of multiple residents not receiving their scheduled medications on two shifts. Findings were reviewed with facility staff via phone during the investigation. An exit interview was conducted with the Administrator via phone on 04/01/2020 where findings were reviewed and an opportunity was given for questions. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it to your licensing inspector within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word ?corrected? is not acceptable. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). If you have any questions, contact your licensing inspector at (540) 589-5216.

Violations:

Standard #:	22VAC40-73-640-A
Description:	Based on staff interview and documentation review, the facility failed to implement their medication management plan regarding methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. EVIDENCE: 1. The facility?s current medication management plan states the following for ?methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes?; Narcotics are double locked and counted by two med staff persons at the beginning and end of each shift. If an RMA has worked a double shift, they still need to count per the policy at the end of the change of shift time. 2. The CONTROLLED DRUG COUNT RECORD form for dates 02/24/2020 ? 03/09/2020 was missing signatures for the following dates/times: 02/27/2020; 3-11 Nurse Off, 02/27/2020; 11-7 Nurse On, 03/09/2020; 3-11 Nurse Off and 03/09/2020; 11-7 Nurse On. 3. The CONTROLLED DRUG COUNT RECORD form for dates 01/29/2020-02/27/2020 was missing signatures for the following date/times: 02/27/2020; 3-11 Nurse off and 02/27/2020 11-7 Nurse On. 4. During phone interview with staff 1 on 03/23/2020 it was revealed that staff 2 did not count narcotics before she left the facility on 02/27/2020.
Plan of Correction:	What: On February 27, 2020 a medication aide left the community during her shift and did not complete her assigned tasks, handing her keys to another medication aide, resulting in medications not being passed to her assigned residents and the narcotic count not completed for her medication cart at he conclusion of the shift with the incoming Medication Aide. What: On the morning of 2/28/2020 when the RCD was made aware of the incident, the narcotic count was completed and found to be an accurate. On 3/2/2020 the RMA was terminated for this incident, following the results of the investigation. From the date of the incident through March 12th, all RMAs received retraining on the requirement of counting narcotics per Community Best Practices. A coaching and counseling on the proper procedures to count narcotics was completed by the Resident Care Director with the RMA who received the keys from the RMA who left without completing the medication pass. Ongoing: RCD will continue to monitor to ensure medication management policies are being followed with continued MAR audits, cart audits, RMA skills audits nd audits of narcotic counts. The results of these audits will be reviewed at the Quarterly Quality Assurance meeting.
Standard #:	22VAC40-73-680-D
Description:	Based on staff interview and documentation review, the facility failed to ensure that medications were administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1. On 02/28/2020, staff 1 provided a written report of an incident on 02/27/2020 that ?7pm meds not given for 100, 200 400 halls, and all halls for 10pm meds.? 2. The February 2020 medication administration record (MAR) for resident 1 did not include initials of staff administering the following medications on 02/27/2020: scheduled 7:30PM dose of Diclofenac Sodium 1% Gel, scheduled 8:00PM dose of Divalproex SOD DR 500 MG Tab, scheduled 7:30PM dose of Mapap Arthritis ER650 MG CPLT, scheduled 8:00PM dose of Pregabalin 50 MG CAP, scheduled 7:30PM dose of Quetiapine Fumarate 25 MG Tab, scheduled 7:30PM dose of Systane Balance 0.6% Eye Drop and scheduled 8:00PM dose of Tubigrip DSG ?E?, 3. The February 2020 MAR for resident 2 did not include initials of staff administering the following medications on 02/27/2020: scheduled 10:00PM dose of Acetaminophen 325 MG Tablet, scheduled 8:00PM dose of Diclofenac Sodium 1% Gel, scheduled 8:00PM dose of Docusate Sodium 100 MG Capsule, scheduled 8:00PM dose of Dorzolamide HCL 2% Eye Drops, scheduled 8:00PM dose of Latanoprost 0.005% Eye Drops, scheduled 10:00PM dose of Methadone 5MG/5ML SOLN (also resident 2 did not receive scheduled 6:00AM dose of Methadone 5MG/5ML SOLN on 02/28/2020) and scheduled 8:00PM dose of Timolol 0.5% Eye Drops. 4. The facility?s EMPLOYEE CORRECTIVE ACTION REPORT stated that ?On 2/27/2020, (staff 2) knew between 5:45 pm and 6pm that she needed to stay over past the end of her 7 pm shift until 11 pm, as the other RMA called out. (Staff 2) left at 7:45 pm w/o finishing her med pass. 35 residents did not receive their evening medications?. This was also revealed during phone interview with staff 1 on 03/23/2020 to be accurate.
Plan of Correction:	What: On February 27, 2020 a medication aide left the community during her shift and did not complete her assigned tasks, resulting in medications not being passed to her assigned residents and the narcotic count not completed for her medication cart at the conclusion of the shift with the incoming Medication Aide. What: On 2/28/2020 the Executive Director and Resident Care Director began an investigation of the incident, placing the RMA on immediate suspension pending the results of the investigation. On 2/28/2020 the facility medical director as well as the physicians stated that there was no adverse effect of any of the missed medications. On 2/28/2020 the residents affected, and their responsible parties were notified. On 2/28/2020, the facility reported RMA to the Board of Nursing to evaluate this RMA, reported the incident to APS and DSS. On 3/2/2020 the RMA was terminated for this incident, following the results of the investigation. From the date of the incident through March 12th, all RMAs received retraining by the Resident Care Director (attached attendance sheet) on the five rights of medication management, Heritage Senior Living Best Practices, and communicating pertinent information when handing off to the incoming RMA. Onging: RCD will continue to monitor to ensure medication management policies are being followed with continued MAR audits, cart audits, RMA skills audits, and audits of the narcotic counts. The results of these audits will be reported at the Quarterly Quality Assurance meeting.