VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Westminster Canterbury on Chesapeake Bay
3100 Shore Drive
Virginia beach, VA 23451
(757) 496-1100

Current Inspector: Lanesha Allen (757) 715-1499

Inspection Date: June 21, 2022 and June 22, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

An unannounced inspection was initiated on 06/21/22 from 9:04am to 3:09 am and on 06/22/22 from 8:15am to 3:24pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A (complaint/self-reported incident) was received by VDSS Division of Licensing on (05/11/22) regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 62 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: A tour of the facility was conducted to include the memory care unit and observation of secured exits located in the memory care unit.

Violations:

Standard #:	22VAC40-73-460-D
Description:	Based on staff interviews and documentation review, the facility failed to provide supervision of resident schedules, care, and activities including attention to the specialized need of wandering from the premises for one resident in care. Evidence: 1. Per the final incident report dated 05/18/22 the resident, was not able to be located for lunch, on 05/11/22; An after action review determined the resident was able to exit the secure unit, then exited the main campus front entrance. 2. Per an interview with staff # 1, #2, #3 and the incident report dated 05/18/22, a general services vendor who did not perceive the individual to be a resident, held open the door for the resident to exit the secure unit. 3. Per an email sent on 06/23/22 to the Licensing Inspector from staff #1, the resident exited the secure unit at 11:27am, and left campus at 11:37am, and was located by a Cape Henry resident around 12:35pm. Per the interview with staff # 1, #2, and #3 a resident at Cape Henry apartments contacted the facility to notify them the resident was at the Cape Henry location. 4. Per the individualized service plan (ISP), the individual has a wander guard to the R ankle; Per an interview with staff #1, #2, and #3 the resident wander guard notifies the staff on duty via page when the resident is near/leaves a secured exit door. The aforementioned staff reported the pager notified the staff when the resident exited the secure unit, however the staff did not respond. Per the aforementioned staff the staff on duty during the incident assumed the notification was received because the resident was returning from an offsite visit with his family. 5. Per the resident ISP dated 05/17/22, the resident has a diagnosis of Alzheimers disease; the resident is disoriented to some spheres, some of the time (person, place, and time); needs supervision with mobility outside of living area. 6. Per the Global Positioning System (GPS) Navigation the distance from the facility to Cape Henry Towers/apartments is 0.6 miles which equals to 3168 feet.
Plan of Correction:	1. A full campus search was initiated when it was identified that Resident #9 had exited the unit. The resident was safely located at a location his wife confirmed familiar to him due to friends residing there. Resident #9 was assessed by a Registered Nurse and Nurse Practitioner to be at baseline, in a pleasant mood, and without acute injury or distress. Visual checks at an increased frequency were initiated, the hallway security camera was changed from motion detection to continuous monitoring, and wearable GPS devices were trialed. Security and the Front Desk were provided a photograph of Resident #9. Therapeutic Recreation identified resident-centered interventions for engagement related to occupation, hobbies, and interests. Resident #9 began attending Connections at least weekly and has continued to do so since the event. 2. Residents residing in the secure memory unit have the potential to be affected. All other residents were accounted for at the time of the incident, and there has not been an elopement since the event on 5/11/22. 3.An after-action review to identify a timeline of events and root causes was performed on 5/11/22 with Administration, Therapeutic Recreation, Security, General Services, Information Technology, and Quality Management. System changes are as follows: a. The security code to the memory unit door was changed on 5/11/22 b. Vendors are supervised by General Services or a designee when providing services to the secure unit as of 5/11/22 c. SouthBay added an audible alarm to the secure memory unit door when it is opened, and a resident with a Wanderguard is within its range on 5/12/22 d. The SARA System was modified to reduce routine ambulation pager alerts so the audible alarm and alert to the pager would indicate the need to staff response on 5/12/22 e. Badge access readers replaced the key code entry pad for the secure memory unit entrance on 5/14/22 f. A Resident Emergency Practice Exercise and staff debrief were conducted on 5/12/22 g. The Emergency Operations Plan and Missing Resident policy were revised in response to these items 4. The interdisciplinary team meets at least four times weekly to review clinical systems, including wandering risk. Findings will be reviewed by the QA Committee and discussed in QAPI meetings as warranted.