VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Mayfair House Senior Living
901 Enterprise Way
Portsmouth, VA 23704
(757) 397-3411

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: Jan. 25, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical Assistance:

Blood glucose orders and orders for insulin administration are to include parameters on when to notify the physician.

Comments:

A renewal inspection was initiated 01/25/2022 and concluded on 01/27/2022. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 15. The inspector emailed the administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed three resident records, two staff records, fire drills, criminal history reports, fire drills, activities calendar menu and staff schedules, submitted by the facility to ensure documentation was complete. The inspector conducted a virtual inspection with the administrator on 01/27/2022. An exit interview was conducted with administrator on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection.

Violations:

Standard #:	22VAC40-73-440-D
Description:	Based on review of residents? records, the facility failed to ensure the Uniform Assessment Instrument (UAI) is completed as required by 22 VAC 30-110. EVIDENCE: The medication administration section on the Uniform Assessment Instrument (UAI) for resident 2, dated 06/16/2021 is not completed.
Plan of Correction:	UAI will be reviewed by Administrator/LPN after completion for accuracy.
Standard #:	22VAC40-73-450-C
Description:	Based on review of residents? records, the facility failed to ensure the assessed needs of the resident are included on the Individualized Service Plan (ISP). EVIDENCE: 1. The UAI for resident 2, dated 06/216/2021 indicates resident requires mechanical and physical assistance with dressing. The ISP dated 06/16/2021 indicates physical assistance only. 2. The January dietary sheet and the January Medication Administration Record (MAR) for resident 2 indicate resident has a diet of Nectar Thickened Liquids. The ISP dated 06/16/2021 indicates regular diet.
Plan of Correction:	ISP/UAI will be reviewed by Administrator/LPN after completion for accuracy of all care needs.
Standard #:	22VAC40-73-680-D
Description:	Based on review of residents? records, the facility failed to ensure medications are administered in accordance with the physician?s or other prescriber?s instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1. Resident 1 has the following order: Sliding Scale Insulin three times daily before meals for DMII-150-199 2U; 200-249 3U; 250-299 5U; 300-349 7U; 350-399 8U; 400-449 10U. 2. The January Blood Glucose log for resident 1 indicates on 01/09/2022 at 4:30pm resident?s blood glucose reading is 147. The MAR indicates 2 units were administered; however resident should not have received any insulin. 3. The January Blood Glucose log for resident 1 indicates on 01/15/2022 at 4:30pm resident?s blood glucose reading is 212. The MAR indicates 2 units were administered; however resident should have received 3 units. 4. The January Blood Glucose log for resident 1 indicates on 01/18/2022 at 7:30am resident?s blood glucose reading is 226. The MAR indicates 2 units were administered; however resident should have received 3 units. 5. The January Blood Glucose log for resident 1 indicates on 01/19/2022 at 4:30pm resident?s blood glucose reading is 183. The MAR indicates insulin was not administered; the resident should have received 2 units. 6.The January Blood Glucose log for resident 1 indicates on 01/22/2022 at 7:00am resident?s blood glucose reading is 154. The MAR indicates insulin was not administered; the resident should have received 2 units. 7. The January Blood Glucose log for resident 1 indicates on 01/23/2022 at 7:00am resident?s blood glucose reading is 153. The MAR indicates insulin was not administered; the resident should have received 2 units.
Plan of Correction:	Electronic Mars were implemented in facility to assist with more accuracy with documentation. Pharmacy oversite conducted by ACT pharmacy for review and discussion concerning documentation and accuracy. In-service presented to Medication Aides by Pharmacy for review on Sliding Scale and hyperglycemia to assist with understanding concerning residents on insulin. Medication Aides will do "buddy checks" with each other, RCC/LPN for accuracy prior to administration of insulin. Physician Orders will include parameters notification of physician with insulin and glucose monitoring.
Standard #:	22VAC40-73-700-1
Description:	Based on review of residents? records, the facility failed to ensure oxygen orders include all required components. EVIDENCE: 1. The oxygen order for resident 3, dated 11/11/2021 does not include the delivery device or oxygen source.
Plan of Correction:	Orders will be reviewed for accuracy including oxygen source and delivery service. Hospice providers will review instructions to include all necessary information. Orders will be reviewed by LPN/RCC.