This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on March 31, 2021 and concluded on May 28, 2021. A self-reported incident was received by the department regarding allegations in the area of medication administration. The Executive Director was contacted by telephone to conduct the investigation. The licensing inspector emailed the Executive Director a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and a violation was issued. Please complete the "plan of correction" and "date to be corrected" for the violation cited on the violation notice and return it to the licensing office within 10 calendar days. Please specify how the violation will be corrected. The plan must contain: 1) step(s) to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation during this inspection. I can be reached at Kimberly.M.Davis@dss.virginia.gov or (804) 662-7578.
Based on a review of facility documentation, the facility failed to ensure that the Medication Administration Record (MAR) contained the initials of the direct care staff administering the medication.
Evidence: The MAR for Resident # 1 was initialed five times by Staff # 1 to indicate the administration of Oxycodone 5 mg tablets on the following dates: March 3, 9, 10, 14, and 23. However, the Individual Resident's Controlled Substance Record for Resident # 1 was signed by Staff # 1 to indicate the administration of Oxycodone 5 mg twelve times with the following dates noted: March 2, 3, 9, and twice on March 10, 13, 14, 22, and 23.
Plan of Correction:
Staff member who committed the violation was terminated. Med techs and nurses were educated to review the narcotic/controlled substance count sheets for PRN medications during shift change. Med techs and nurses were taught to then compare the documentation on the count sheet to the documentation on the Medication Administration Record (MAR). Med techs and nurses were trained to verify that the documentation on the count sheet and the MAR match. Lastly, med techs and nurses were educated to document this verification process on the count sheet. A nurse, the Assistant Care Director, or Resident Care Director will routinely audit the count sheets to ensure this process occurs as instructed.
Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.
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