VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Renaissance of Annandale
7112 Braddock Road
Annandale, VA 22003
(703) 256-2525

Current Inspector: Marshall Massenberg (804) 543-5188

Inspection Date: March 5, 2020 and March 8, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical Assistance:

Discussed documentation of care shall be retained in resident records and orders shall be organized chronologically in the resident's record. (Standard 560, 650) Discussed use and documentation of restraints in emergency and nonemergency situations. (Standard 710)

Comments:

Licensing Inspector (LI) conducted unannounced complaint investigation on 3/05/2020 and on 3/8/2020 regarding medication and treatment administration and reporting, restraints and building access. LI reviewed resident records, medication and treatment administration records, and observed resident rooms and building. Staff and family interviewed and Licensing Inspector spoke with Executive Director, Director of Nursing and Memory Care Director. While the preponderance of evidence gathered during the investigation did not support all of the allegations, the complaint is deemed valid as violations related to standards 680 and 710 were cited. Violations and risk ratings discussed with Executive Director. 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 standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation and if you have any questions please call (703) 895-5627 or contact me via e-mail at jeannette.zaykowski@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-680-E
Complaint related:	No
Description:	Based on record review and interview, facility failed to ensure that medical procedures ordered by a prescriber shall be provided according to instructions and documented and the documentation shall be maintained in the resident's record. Evidence: Resident #1's record was reviewed from 12/1/2019 through 3/5/2020 and Vitamin A and D ointment for rash ordered on 1/22/2020 was not documented as given on 2/11/2020 and documentation of 2/8 notifications to provider for Blood Glucose (BG) readings greater that 400 as ordered on 2/28/2020 were not in record for a BG of 403 on 2/16/2020 and for a BG of 465 on 2/26/2020.
Plan of Correction:	The Resident Services Director spoke with each Nurse that failed to document appropriately that a medication, ointment and/or treatment was given on the day(s) in question. (Even though the nurse states it was given). The Resident Services Director and Memory Care Director conducted an In-Service on March 18, 2020 in which all Nursing Staff that may administer Medications was trained on the importance of Documenting any/all medications, ointments and treatments on the MAR (Medication Administration Record) and/or on the Nursing and/or Physician Notes page within the Healthcare Record Chart. The Resident Services Director and/or Designee will review the MAR?s weekly to ensure compliance. Initiated 4/6/2020 and Ongoing. (sic)
Standard #:	22VAC40-73-710-E
Complaint related:	No
Description:	Based on observation, record review and interview, facility failed to ensure that when restraints are used in nonemergencies, the following conditions shall be met: the restraints shall be used in accordance with the resident's service plan which documents the need for the restraint when appropriate; physician orders for medical/orthopedic restraints must be reviewed by the physician at least every three months and renewed if the circumstances warranting the use of the restraint continue to exist; the facility shall explain the use of the restraint and potential negative outcomes to the resident or his legal representative and the resident's right to refuse the restraint and shall obtain the written consent of the resident or his legal representative; and the facility shall notify the resident's legal representative after the initial administration of a nonemergency restraint and shall keep the legal representative informed about any changes in restraint usage and with a notation made in the resident's record of such notice, including the date, time, person notified , method of notification, and staff providing notification. Evidence: On 3/8/2020 between 10:35 p.m. and 11:30 p.m., 4/32 residents were observed in bed with pillows positioned on the side of the resident under a flitted sheet and Individualized Service Plans (ISP's) for Resident #1 dated 2/7/2020, Resident #2 dated 8/28/2019, Resident #3 dated 10/10/2019 and Resident #4's dated 12/6/2019 did not document positioning with pillows; and records for Residents #1, #2, #3 and #4 did not include orders and other written documentation required for restraints signed and dated by the providers and the legal representatives.
Plan of Correction:	The Resident Service Director meet will all of the Night Shift Nursing Staff on March 18, 2020 and re-emphasized the importance of communicating to the Nursing Director if/when a resident may require re-positioning pillows to ensure the safety and well being of the resident, so that the Resident Service Director and/or Designee can follow the proper DSS protocol in obtaining (1) proper Physician?s order and (2) Gain approval from the Responsible Party (RP)/Power of Attorney (POA) to utilize such a treatment for the resident. The Resident Services Director and/or Designee will evaluate each resident to determine if alternative methods and/or interactions can occur, until all other options are exhausted? If positioning is still required, then the RSD and/or Designee will obtain the proper Physician?s Orders and Approval from the RP and/or POA to utilize positioning pillows for the residents that require it for their safety and wellbeing. Residents ISP (Individualized Service Plan) will be updated and ongoing Documentation will be adhered to. The Resident Services Director and/or Designee will ensure that each residents Physician?s Order are re-approved every 3 months as needed and their respective ISP are updated and documented as well. Completed 4/6/2020 (sic)