VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Regency at Augusta
43 Pinnacle Drive
Fishersville, VA 22939
(540) 213-4400

Current Inspector: Jill James (540) 418-2631

Inspection Date: Feb. 18, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical Assistance:

1. Ensure medication refills are requested at least seven days prior to the last dose being administered and document the notification fully in the resident's record. 2. Ensure controlled count sheets are maintained in an organized manner and that all records are maintained as required.

Comments:

The licensing inspector conducted an unannounced complaint inspection in response to a complaint that was received by the licensing office on 2/10/2022. Interviews were conducted with residents, staff and a family member relating to allegations that a medication was not ordered in a timely manner and was not administered as ordered. The information gathered during the investigation supports the allegations, so the complaint is determined to be valid. Please complete the columns for "description of action to be taken" and "date to be corrected" for each violation cited on the violation notice, and then return a signed and dated copy to the licensing office within 10 calendar days of receipt. If you have any questions, contact your licensing inspector at (540) 430-9258.

Violations:

Standard #:	22VAC40-73-640-A
Complaint related:	Yes
Description:	Based upon documentation and interviews, the facility failed to ensure one of four residents medications were ordered in a timely manner to avoid missed doses. Evidence: 1. Resident 1 had a physician's order signed 11/30/2021 for, "fentanyl 12mcg/HR PT72 every 3 days, place topically every 3 day at 2200 (per residents request)." 2. On 2/28/2022, the LI interviewed resident 1 who stated, "I went five days waiting for one and got it on day six. I missed two doses." 3. The February EMAR was blank for 2/5/2022 and 2/8/2022 for fentanyl 12mcg/HR PT72. 4. On 2/10/2022, the LI received an email stating staff 1 notified resident's daughter on 2/4/2022 that a refill for the fentanyl patch was needed. 5. On 3/4/2022, the LI interviewed collateral 1 who stated she was notified on 2/5/2022 of the need for a refill of the fentanyl patch. 6. The facility's medication management plan stated on page 6, "All medications from private pharmacies or provided by families must be called in for refills timely to ensure adequate supply. Nurses may call the private pharmacy to request refills if there are refills left on prescription. As a courtesy, nurses and medication aides will attempt to notify the family of refill needs at least 7 days prior to medication supply depletion."
Plan of Correction:	Resident now receives her medications through the community pharmacy. When someone has a narcotic or other medication ordered, that a family member manages, the community will notify the family, physician and pharmacy seven days prior to the medication running out. The DHW and director of innovations memory care (DIMC) will ensure that weekly cart audits are conducted on Tuesdays. They will ensure proper documentation from the registered medication aides (RMAs).
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based upon documentation and interviews, the facility failed to ensure one of four residents received one medication as ordered. Evidence: 1. Resident 1 had a physician's order signed 11/30/2021 for, "fentanyl 12mcg/HR PT72 every 3 days, place topically every 3 day at 2200 (per residents request)." 2. On 2/28/2022, the licensing inspector (LI) interviewed resident 1 who stated, "I went five days waiting for one and got it on day six. I missed two doses." 3. On 2/18/2022, the LI interviewed the executive director (ED) who stated resident 1 did not receive the fentanyl patch on 2/5/2022 and 2/8/2022. 4. The February electronic medication administration record (EMAR) was blank for 2/5/2022 and 2/8/2022 for fentanyl 12mcg/HR PT72.
Plan of Correction:	Resident received medication on 2/10/2022. The daughter brought the medication to the facility on 2/9/2022. The medication was ready for pick up from the resident's chosen pharmacy on 2/4/2022. Resident will now be receiving all of her medications delivered from the community pharmacy. The community will now administer all of the resident's medications versus just this one. The resident's EMAR now shows that the resident's medications are administered by community and will send alerts/notifications to ED and director of health and wellness (DHW) for any missed medications.
Standard #:	22VAC40-73-680-I
Complaint related:	No
Description:	Based upon documentation and an interview, the facility failed to ensure one of four February EMARs reviewed documented omissions. Evidence: 1. The February EMAR for resident 1 was blank for fentanyl patch on 2/5/2022 and 2/8/2022. Staff initials were not listed and circled and no notations were documented as to why the medication was not administered on these dates. 2. On 2/18/2022, the LI interviewed the administrator who also checked the EMAR and stated the omissions were not documented.
Plan of Correction:	Resident's EMAR has been updated to reflect that the community administers medications. This will ensure that the medication will "pop" to alert the RMAs that it is due. This will allow the RMAs to sign and create a notation if a medication is missed. During daily EMAR audits by the DHW and DIMC, it will be observed if a medication is not given/not documented on. Follow up will occur at that time.