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: April 12, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical Assistance:

Recommended all medication administration records and physicians' orders be audited and staff observed administering medications on a frequent basis to ensure standards are being followed.

Comments:

An unannounced focused monitoring inspection was conducted on 4/12/2022 from approximately 9:03 am to 11:55 am. Medication administration observations were completed for one resident. Individual staff and resident interviews were conducted. Three residents' March and April medication administration records and physicians' orders were reviewed. The area of noncompliance was in medication administration documentation. Staff answered all questions and obtained all information requested. Thank you for your assistance and cooperation.

Violations:

Standard #:	22VAC40-73-680-H
Description:	Based upon documentation and interviews, the facility failed to ensure staff initialed the electronic medication administration records (EMARs) when medications were administered for two of the six EMARs reviewed. Evidence: 1. The March EMAR for resident 1 was blank for Sinemet on 3/27/2022 for the 10:00 am and 1:00 pm doses. 2. The March EMAR for resident 3 was blank for Tylenol, Norvasc, aspirin, blood pressure check, Ferrous Gluconate and Metoprolol for the morning doses on 3/27/2022. 3. On 4/12/2022, the licensing inspector (LI) interviewed resident 3 who stated she had not missed her morning medications since she has been at the facility. 4. On 4/12/2022, the LI interviewed the executive director (ED) who stated staff 1 was the staff who was on duty to administer medications on the 7:00 am to 3:00 pm shift on 3/27/2022 and that she is no longer an employee at the facility.
Plan of Correction:	Executive director has posted the medication management plan to every med cart to be available and reviewed by all medication staff. Regional staff will assist in auditing of all med carts and EMARs on 4/18/2022. The day shift nursing staff will do so weekly and review with ED any missed submissions. Day shift nursing supervisor and director of memory care are reviewing the missed med report every morning Monday through Friday and will report discrepancies to ED.