VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Showalter Center
1060 Showalter Drive
Blacksburg, VA 24060
(540) 443-3427

Current Inspector: Rebecca Berry (276) 608-3514

Inspection Date: July 19, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: N/A The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 06/27/2022 regarding allegations in the area(s) of: Medication administration error Number of residents present at the facility at the beginning of the inspection: 80 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. N/A Number of resident records reviewed: 2 Number of staff records reviewed: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: N/A Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-680-B
Description:	Based on documentation review, the facility failed to ensure that medications shall remain in the pharmacy issued container, with the prescription label or direction label attached until administered to the resident. EVIDENCE: 1. The facility incident self-report, dated 06/27/2022 at approximately 08:30, states ?Staff 1 was in charge of the 3rd floor medication pass. She was preparing medication for resident 2 when she saw resident 1 exit the elevator. Staff 1 requested that resident 1 wait a moment in order for staff 1 to administer her medication. Resident 1 agreed to wait. Staff 1 set resident 2 medication to the side and pulled the cards for resident 1. While staff 1 was looking down, resident 1 approached the cart, picked up resident 2 medication and swallowed it. Staff 1 was unable to stop resident 1. Ashley Cupp, NP was notified of the medication error and advised LPN to take resident?s vital signs every hour. At the second reading, the resident?s pulse dropped from 72 to 40 and her blood pressure dropped from 128/68 to 100/50. NP advised staff to send the resident to the ER.? 2. Premier Geriatric Solutions, PLLC hospital progress notes, dated 06/28/2022, indicated that resident 1 presented with hypotension and bradycardia due to medication error. The hospital notes stated ?Pt is seen today to reevaluate s/p ER visit after receiving another resident?s medications by mistake. Blood pressure dropped to 100/50 and HR to 48.? 3. Upon review of resident 2 current physician?s orders, dated 06/21/2022, resident 1 accidentally received the following 08:00 medications: Allopurinol tab 100mg (gout), Finasteride tab 5mg (benign prostatic hypertrophy), Furosemide tab 40mg (congestive heart failure), Hydrochlorothiazide tab 25mg (congestive heart failure), Metoprolol Tartrate tab 75mg (atrial fibrillation), Oxycodone/APAP tab 7.5/325mg (pain), Potassium Cl ER tab 20meq (supplement), Trintellix tab 20mg (depression).
Plan of Correction:	Staff Development will provide education to LPNs/RMAs on the following: ? Medications shall remain in the pharmacy issued container, with the prescription label or direction label attached until administered to the resident. ? Not engaging with a resident until ready to administer that resident?s medication. ? When pulling medication, focusing solely on that pass before moving on and keeping the medication within line of sight. ? Medication on the cart in a cup is the clinician?s responsibility. (08/31/2022) Two medication passes will be completed with Staff 1 within 60 days by Staff Development/DON. (10/2022) A performance evaluation will be completed on Staff 1 in three months and six months by DON/Designee. (09/2022 & 12/2022) All LPNs/RMAs signed off on the Medication Management Plan Review in the month of July. (07/2022) Staff Development provided education on the 8 Rights of Medication Administration. (07/2022) The Medication Error Policy was reviewed with LPNs/RMAs by DON on 7/11/2022. Staff 1 immediately received verbal counselling and one on one education on the above with the Risk Management Director. (06/27/2022)