VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Karolwood Gardens at Portsmouth
1 Bon Secours Way
Portsmouth, VA 23703
(757) 686-9100

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

Inspection Date: March 24, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

A non-mandated self-report inspection was conducted on 03-24-2022 from 1:38 PM to 2:58 PM. A self-reported incident was received by the department regarding the areas of Additional Requirements for Facilities that Care For Adults with Serious Cognitive Impairments. A tour of the safe, secure environment was conducted. The resident involved in the self-report was observed as well as their record. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and violations were issued. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-1150-A
Description:	Based on observation, record review and interview, the facility failed to ensure doors that lead to unprotected areas be monitored or secured through devices that conform to applicable building and fire codes, including door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, pressure pads at doorways, delayed egress mechanisms, locking devices, or perimeter fence gates for residents residing in a safe, secure environment. Evidence: 1. On 3/17/22, Resident #1 who resides in a safe, secure environment was observed at the front entrance area of the facility. The March MAR for Resident #1 indicates the two following orders; ?Monitor left leg every shift for redness and remove wander guard if redness develops? and ?Apply secure care bracelet, check for placement every shift. Check for functioning once per week every shift ? diagnosis: elopement risk.? These two items on the MAR were not signed as completed on various shifts throughout 3/1/22-3/23/22. 2. After the incident occurred, it was identified the secure care bracelet was on the left leg of Resident #1?s walker and not physically on the resident. Resident #1 was ambulating without the use of their walker, therefore able to exit the safe, secure environment. 3. Resident #1?s record does not document redness from the secure bracelet or when the secure bracelet was removed from the resident?s body and put onto their walker. 4. Resident #1 was observed on 3/24/22 at the time of inspection to have a secure bracelet on their right leg and on the left leg of their walker. 5. Staff #1 acknowledged the inconsistency of the monitoring of the secure care bracelet of the resident and the discrepancy of the current placement of the secure care bracelet on Resident #1.
Plan of Correction:	Staff has placed the wonder guard to resident #1?s left ankle area on 3/24/2022. All residents at Memory Care unit were audit for wonder guard placement and its working condition on 3/17/2022. A new wonder guard was placed on #1 resident?s right ankle in addition to the one on her walker. Director of Resident Care has completed the in-service on wonder guard placement check and monitor to Memory Care unit staff. Director of Resident Care or designee will monitor the practice weekly to assure the compliance. The result of the audit will be presented to facility QAPI committee for review and recommendations.