VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Saint Francis Home
65 West Clopton Street
Richmond, VA 23225
(804) 231-1043

Current Inspector: Yvonne Randolph (804) 662-7454

Inspection Date: Jan. 15, 2020 and Jan. 16, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

An unannounced, self-reported, monitoring inspection was initiated on January 15, 2020, from 11:00 a.m. to 4:45 p.m. for Saint Francis Home. Upon arrival the licensing representative met with the administration team regarding the nature of the self report concerning a suspicious death of a total care resident involving side rails. The administration confirmed that the resident was recently approved for skilled care but was waiting for an available bed. After the entrance conference, staff interviews were conducted and the documentation review was initiated. New violations were cited based upon the interviews and documentation provided by the facility. A second unannounced self-reported monitoring inspection was conducted on January 16, 2020, from 11:10 a.m. to 2:20 p.m. for Saint Francis Home. The assigned licensing representative met with the administration staff briefly in order to conduct the inspection. Additional information was gathered as it related to monitoring inspection. The information gathered during the monitoring inspections determined that the standards were not in compliance and violations were cited. Please complete "the plan of correction" and "date to be corrected" for each violation cited on the violation notice and return it within 10 calendar days from today. Your plan should also specify how you will correct each violation, an intended plan for future compliance, a job title for the responsible staff for implementing the plan of correction ,and monitoring preventive measures. You may contact me at (804) 662-9432 or e-mail me at Vashti.Colson@dss.virginia.gov to discuss any questions. Thank you for your cooperation during this inspection.

Violations:

Standard #:	22VAC40-73-40-A
Description:	VIOLATION: Based upon the record review, the facility failed to adhere to the facility's own policies and procedures . EVIDENCE#1: Per the facility's restraints policy dated 11/08/2011, the facility failed to adhere to the following policies: 1) Restraints shall only be applied by direct care staff who have received training in there use; 2) The facility shall closely monitor the resident's condition, which includes checking on the resident at least every 30 minutes; 3) The facility shall assist the resident as often as necessary , but no less than 10 minutes every hour, for his hydration , safety , comfort , range of motion , exercise, elimination and other needs; 4) The facility shall release the resident from restraint as quickly as possible; and 5) Direct care shall keep a record of restraint usage outcomes, checks and any assistance required, and note any unusual occurrences or problems. Per the self-reported incident report the following occurred as of 1/3/2020: "At about 12:15 a.m. on 1/03/2020 resident was discovered in her room , unresponsive, having what appeared to be , attempting to get out of her hospital bed again unassisted with upper half side rail in up position, resident back up against the bed, legs on the floor , her face /head/neck was noted as pressed on the side rail between rail and mattress." "Long history of resident utilizing the side rails for positioning herself and getting out of bed unassisted. At times, resulting in a fall to the ground. Hence a cushion /mat on the floor to assist in preventing injury. " During the record review, the facility failed to provide evidence that the direct care staff received training on non-emergency or general restraints. Three out of three staff records reviewed did not have the required training for the use of restraints concerning resident #1's level of care. Throughout the record review, the facility failed to provide the licensing representative with the required documentation that would confirm the facility?s record of (30) minute monitoring checks for resident #1 concerning the resident?s condition, safety , range of motion, or basic healthcare needs. Staff interviews confirmed that that the direct care staff members conducted required monitoring checks for resident #1, ranging from every thirty minutes to every two hours, but the facility failed to maintain evidence that would confirm compliance per the facility's policy.
Plan of Correction:	Saint Francis Home?s primary goal is to provide care and safety to the extent possible to all Residents of this Assisted Living Facility. The utilization of the bed-rail in this particular case was for positioning, support and as a nursing intervention to assist in preventing falls from the bed. Its implementation was never intended to be utilized as a physical restraint. The facility currently does not have any residents who are using ? side rails or other devices that may be considered a physical restraint. The facility restraint policy has been reviewed by the Administrator and DON and is consistent with current ALF regulations. The facility will develop a side rail policy that includes all orders for use of side rails will be approved by the DON and attending physician prior to application and each resident who requests a side rails will have an assessment completed prior to application to determine if the device meets the definition of being a restraint. A written physician?s orders will be obtained and signed by the physician. Staff will document monitoring of the resident while using the side rail. The side rail assessment will be completed at least annually for a licensed nurse and if the resident has a significant change in function and safe use of the device. Direct Care Staff was educated on facility restraint policy and standards for licensure for ALF on 1/24/2020. Direct care staff will be re-educated in the facility restraint policy by the DON. Direct care staff will be educated on the side rail policy and licensed staff will be educated on completion of the side rail assessment. The Administrator and/or DON will notify hospice providers of the side rails and restraint policy. The DON and/or designee will monitor assessment and signed physician order, and documentation of use and staff monitoring of any side rail or restraint upon application and at least monthly x 3 months.
Standard #:	22VAC40-73-300-B
Description:	VIOLATION: Based upon the record reviews, the facility failed to maintain a written communication log among direct care staff. EVIDENCE: During the record review the communication log or 24 hour reports had limited to no information concerning resident #1's hydration, comfort, range of motion, restraint usage, checks, and any assistance provided by staff as of 1/2/2020 and 1/3/2020. The director of nursing confirmed that the direct care did not log such efforts in the communication logs. Care notes concerning resident #1?s comfort and check prior to the incident report of 1/3/2020 were documented on the following dates after the reported incident: 1/6/2020 and 1/04/2020. The 1/6/2020 care note stated the following: ?I ____________ on Thursday, Jan.2, 2020 assisted resident __________ to bed. She was toileted wash up and changed in to night clothes. After that we transferred from the chair to the bed. Total care was done between 7:40 p.m. -7:45 p.m. ?Care notes dated on 1/04/2020 stated the following: ?On January 3rd at 11:57 p.m. I clocked in and counted DCH and Vesey med carts with my shift coordinator. After we counted, I immediately went to _____ check on her. I slowly opened the door and at first, was confused until I cut on the light. The resident was caught between the mattress and the top railing of her bed. She was a yellowish color and had drool coming out of her mouth. I then called my shift coordinator to come to her room and see the resident when she got there we took her head out of the railing and started calling hospice and the administrator. After hospice got here we were informed by __________ that we needed to call the police and have them investigate. When the officer arrived I reported my story as it happened and spoke with the medical examiner.? The electronic charting notes only documents that medications were administered to the resident around 8:28 p.m. on 1/2/2020 as it relate to monitoring checks prior to the residents death.
Plan of Correction:	The facility will maintain a written communication log for all orders regarding side rails and/or restraints. Nursing staff will be re-educated in use of the 24-hour report by the DON and/or designee. Nursing staff will be re-educated on the principles of accurate and timely documentation by the DON / designee. The entries of 01/04/20 and 01/06/20 were statements obtained from the direct care staff for investigative purposes only and were not intended to be part of the clinical record. The staff persons who wrote the entries of 01/04/2020 and 01/06/2020 will be re-educated on the proper way to document ?late entries? into the medical record by the DON / designee. The DON and/or designee will monitor assessment and signed physician order, and documentation of use and staff monitoring of any side rail or restraint upon application and at least monthly x 3 months.
Standard #:	22VAC40-73-390-A
Description:	VIOLATION: Based upon the record review, the facility failed to ensure that each resident record has a signed written agreement prior to the date of admission. EVIDENCE: Resident record #1 did not have a documented resident agreement accessible to the licensing representative during the January 15, 2020, record review. During the inspection, the administration team confirmed that, at this time, the business record for resident #1 could not be located in order to review the resident agreement.
Plan of Correction:	The Resident?s Administrative File is separate from the Medical Record and is stored within the office of the Administrator. The ?Written Agreement? or ?Residency Contract? is stored within this file. The Administrative File had been alphabetically misfiled within the File Cabinet and was not readily located by the Administrator and assistant. The ?missing file? was located within the cabinet after the Licensing Specialist concluded her monitoring visit. The Administrative File and ?Written Agreement was provided to the Licensing Specialist the next day, January 16, 2020.
Standard #:	22VAC40-73-560-E
Description:	VIOLATION: Based upon the record review, the facility failed to make all records accessible for the licensing representative. EVIDENCE: The resident agreement and business record for resident #1 was not accessible to the licensing representative during the January 15, 2020, inspection. The administration team was given the opportunity to locate resident #1's agreement and business file. The facility could not provide the evidence during the January 15, 2020 ,inspection that would dispute the cited violation.
Plan of Correction:	The Resident?s Administrative File is separate from the Medical Record and is stored within the office of the Administrator. The ?Written Agreement? or ?Residency Contract? is stored within this file. The Administrative File had been alphabetically misfiled within the File Cabinet and was not readily found by the Administrator and assistant. The ?missing file? was located within the cabinet after the Licensing Specialist concluded her monitoring visit. The Administrative File and ?Written Agreement was provided to the Licensing Specialist the next day, January 16, 2020.
Standard #:	22VAC40-73-710-C
Description:	VIOLATION: Based upon the inspection documentation, the facility did not adhere to each condition of the standard in order to implement the use of non-emergencies restraints. EVIDENCE#1: During the January 15, 2020, record review, resident record #1 had a physician order, dated 11/26/2019, that stated the following : " Hospital Bed 1/2 side rails to aide in turning and repositioning while in bed have elevated for meals in bed, drinking fluids." The original order dated 11/26/2019, failed to have the date when the prescribing physician approved the order and the signature of the prescribing physician. EVIDENCE# 2: On 01/16/2020,the second day of the record review, the 11/26/2019 order for ? side rails was signed by the physician but it was dated and approved as of January 07, 2020. The facility could not provide evidence that would clarify the discrepancy between the date the order was written and the date the order was signed/approved.
Plan of Correction:	The physician?s order for any side rail and/or restraint will include the frequency for monitoring by staff and will be transcribed onto the Treatment Administration Record [TAR]. Licensed staff [LPNs and RMAs] will be educated by the DON and/or designee on the order content and use of the TAR for documentation. The DON and/or designee will monitor assessment and signed physician order, and documentation of use and staff monitoring of any side rail or restraint upon application and at least monthly x 3 months.
Standard #:	22VAC40-73-710-D
Description:	VIOLATION: Based upon the inspection documentation and staff interviews, the facility did not adhere to each condition of the standard concerning thirty minute monitoring checks and documenting restraint usage , outcomes, and assistance. EVIDENCE: The director of nursing confirmed that direct care staff monitoring rounds for resident #1 varied from 30 minutes to 2 hours. Per the electronic charting notes, resident #1 was observed during a medication pass on 1/2/2020 at 8:38 p.m. Per the written statements of direct care staff member for the facility's incident report, resident # 1 was last observed by a direct care staff member on 1/2/2020 around 10:00 p.m. prior to her expiration on the morning of 1/3/2020. Due to the limited charting notes, 24 hour communication logs entries, and case notes, the facility failed to provide ample evidence that the facility's direct care staff conducted the required thirty minute monitoring checks prior to resident #1's expiration.
Plan of Correction:	The physician?s order for any side rail and/or restraint will include the frequency for monitoring by staff and will be transcribed onto the Treatment Administration Record [TAR]. Licensed staff [LPNs and RMAs] will be educated by the DON and/or designee on the order content and use of the TAR for documentation. The DON and/or designee will monitor assessment and signed physician order, and documentation of use and staff monitoring of any side rail or restraint upon application and at least monthly x 3 months.