VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Chesapeake Place
1500 & 1508 Volvo Parkway
Chesapeake, VA 23320
(757) 548-0808

Current Inspector: Lanesha Allen (757) 715-1499

Inspection Date: Aug. 12, 2021 , Aug. 13, 2021 and Aug. 16, 2021

Complaint Related: Yes

Areas Reviewed:

Staffing and Supervision Admission, Retention, and Discharge of Residents Resident Care and Related Services Buildings and Grounds

Comments:

A non-mandated complaint inspection was initiated on 08-12-2021 and concluded on 08-16-2021. A complaint was received by the department regarding allegations in the areas of Staffing and Supervision, Admission, Retention, and Discharge of Residents, Resident Care and Related Services, and Buildings and Grounds. 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 licensing inspector conducted an on-site observation at the facility on 08-13-2021. The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. Any violations not related to the complaints but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-650-A
Complaint related:	No
Description:	Based on record review and interview, the facility failed to ensure no medications are discontinued by the facility without a valid order from a physician. Evidence: 1. Resident #3?s current signed physician?s orders dated 05-04-2020 documented, ?Aspirin 325mg- take 1 tablet by mouth once daily for Hypertension.? 2. Resident #3?s May 2021 Medication Administration Record (MAR) documented the Aspirin 325mg was ?DC?d? [discontinued]. The resident last received Aspirin 325mg on 05-21-2021. The May 2021 and June 2021 MAR?s did not include documentation that Aspirin 325mg was administered on 05-22-2021 through 06-30-2021. 3. Staff #1 and staff #2 did not provide documentation verifying staff administered Aspirin 325mg to resident #3 during the aforementioned dates. Staff #1 and staff #2 acknowledged the facility did not have a valid physician?s order to discontinue resident #3?s Aspirin 325mg.
Plan of Correction:	RCD and RCC will review discharge summaries and/or new orders with PCP. We will get clarification any and all medication changes and make sure we have signed POS for each new medication, change and or discontinued medications.
Standard #:	22VAC40-73-680-D
Complaint related:	No
Description:	Based on record review and interview, the facility failed to administer medications in accordance with the physician?s instructions. Evidence: 1. Resident #1?s current signed physician?s orders dated 05-06-2021 documented, ?Cyclobenzapr 5mg- Take 1 tablet by mouth every 8 hours.? 2. Resident #1?s May 2021 and June 2021 Medication Administration Records documented staff administered Cyclobenzapr 5mg at 8:00 AM, 2:00 PM, and 7:00 PM on 05-06-2021 through 06-04-2021. 3. Staff #1 and staff #2 acknowledged resident #1?s Cyclobenzapr 5mg was not administered every 8 hours as instructed by the physician.
Plan of Correction:	RCD and RCC has requested pharmacy to send daily MAR to RCD. RCD will in-service RMAs as to how to document MAR, if needed due to technical issues.
Standard #:	22VAC40-73-680-I
Complaint related:	No
Description:	Based on record review and interview, the facility failed to ensure the Medication Administration Record (MAR) included the initials of direct care staff administering the medications. Evidence: 1. May 2021 MAR?s did not include the initials of direct care staff administering the following scheduled medications: A. Resident #1?s 2:00 PM Cyclobenzapr 5mg on 05-06-2021, 05-12-2021, 05-13-2021, 05-19-2021, and 05-23-2021; B. Resident #3?s Furosemide 20mg on 05-08-2021, 05-14-2021, 05-18-2021, 05-22-2021, 05-24-2021, and 05-25-2021; Losartan 100mg on 05-14-2021 and 05-25-2021; Venlafaxine 150mg on 05-20-2021 and 05-25-2021; and Aspirin 81mg on 05-01-2021 through 05-21-2021. 2. Staff #1 and staff #2 acknowledged the aforementioned dates did not include the initials of the direct care staff administering the medications.
Plan of Correction:	RCD and RCC will verify medication times entered by the pharmacy are correct prior to approving an order.