VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Birch Ridge (Augusta CO)
54 Imperial Drive
Staunton, VA 24401
(540) 885-0065

Current Inspector: Jessica Gale (540) 571-0358

Inspection Date: Sept. 22, 2021 and Sept. 23, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical Assistance:

Conduct regular in-services on the importance of ensuring the five rights of medication administration and always completing one resident's medication administration before moving on to the next. Also, conduct regular medication administration observations with all staff who administer medications and document the observations in the staff records.

Comments:

A non-mandated self-report inspection was initiated on 9/22/2021 and concluded on 9/23/2021. A self-report was received by the department regarding allegations in the area of resident care and related services. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and a violation was issued. Any violations related to the self-report can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-680-D
Description:	Based upon documentation and an interview, the facility failed to ensure one of two residents' medications were administered as ordered by the physician and in accordance with the standards of practice as outlined in the current medication aide curriculum. EVIDENCE: 1. A major incident report submitted on 9/5/2021 stated on 9/4/2021 at 5:06 pm, staff 1 administered resident 1 the scheduled 4:00 pm medications along with Buspirone 10mg, Eliquis 2.6mg, Gabapentin 100mg, Metoprolol Tartrate 25mg and Senna Docusate 8.6-50, which were for resident 2. 2. The signed physician's orders for resident 1 for 4:00 pm included Cyclopentolate 1% eye drops, Ipratropium 0.06% nasal spray, Vitamin C, Warfarin Sodium 2mg and Warfarin Sodium 3mg. 3.The September medication administration record (MAR) for resident 1 listed the 4:00 pm medications as Cyclopentolate eye drops, Ipratropium 0.06% nasal spray, Vitamin C, Warfarin Sodium 2mg and Warfarin Sodium 3mg. 3. The September MAR for resident 2 listed the 4:00 pm medications as Buspirone 10mg, Eliquis 2.5mg, Gabapentin 100mg, Metroprolol Tartrate 25mg and Senna Docusate 8.6-50. 4. On 9/23/2021, the licensing inspector (LI) interviewed staff 1 who stated she prepared the medications for resident 2 and then resident 1 came and she set the medication cup for resident 2 aside and pulled the medications for resident 1. She stated she then mistakenly placed resident 1's medications into the cup that had the medications already prepared for resident 2 and administered them all to resident 1. 5.. Section 4.2.A.4 of the current medication aide curriculum states, "Get the medication container from the cart/cabinet and read the label to verify the: right client, right drug, right dose, right route, right time." 6. Page 8, letter E of the current medication aide curriculum states, "Meidcation aides may not pre-pour medications for anyone (self included).
Plan of Correction:	1. Registered medication aide (RMA) will complete med refresher training class by 10/18/2021. 2. Wellness coordinator will conduct weekly observation of medication pass by RMA and complete a performance sheet, for a duration of 60 days. 3. RMA will review with wellness coordinator the company med plan policy by 10/18/2021. 4. A monthly performance assessment will be conducted by executive director and wellness coordinator following 60 days, for a time period of four months. 5. Wellness coordinator will conduct a meeting with all RMAs to review company med plan policy by 10/18/2021. 6. Wellness coordinator will conduct a quarterly medication observations pass with all RMAs.