A non-mandated complaint inspection was initiated on August 18, 2021 and concluded on September 28, 2021. A complaint was received by the department regarding allegations in the areas of resident care. The resident care director was contacted by telephone to conduct the investigation. The licensing inspector emailed the resident care director a list of documentation required to complete the investigation. The licensing inspector conducted an on-site observation at the facility on August 24, 2021. The evidence gathered during the investigation supported some of the allegation(s) of non-compliance with standards or law, and violations were issued. Please complete the "plan of correction" and "date to be corrected" for each 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 some resident interviews and a review of the facility's call bell response log, the facility failed to provide prompt response by staff to the residents' needs to ensure that care provision and service delivery were resident care centered to the maximum extent.
Evidence: -The facility's call bell response log for Resident # 1 indicated the following: In June 2021 there were approximately 15 instances where it took 8-20 minutes for staff to clear the call bell after accepting it. There were approximately 13 instances where it took staff 21-30 minutes. In July 2021 there were approximately 29 instances where it took 8-20 minutes and approximately 13 instances where it took 21-30 minutes. In August 2021 there were approximately 27 instances where it took 8-20 minutes and approximately 4 instances where it took 21-30 minutes. -The facility's call bell response log for Resident #2 indicated the following: In June 2021 there were approximately 33 instances where it took staff 8-20 minutes to clear the call bell after accepting it and approximately 19 instances where it took 21-30 minutes. In July 2021 there were approximately 32 instances where it took 8-20 minutes and approximately 8 instances where it took 21-30 minutes. In August 2021 there were approximately 22 instances where it took 8-20 minutes, approximately 10 instances where it took 21-30 minutes, and 1 instance where it took 31-39 minutes. -The facility's call bell response log for Resident # 3 indicated the following: In June 2021 there were approximately 72 instances where it took staff 8-20 minutes to clear the call bell after accepting it and approximately 13 instances where it took 21-30 minutes. In July 2021 there were approximately 60 instances where it took 8-20 minutes and approximately 9 instances where it took 21-30 minutes. In August 2021 there were approximately 35 instances where it took 8-20 minutes, approximately 6 instances where it took 21-30 minutes, and 1 instance where it took 31-39 minutes. -Two of the residents interviewed confirmed that staff did not respond quickly when they pulled the call bell.
Plan of Correction:
1. Specific steps taken to correct non-compliance with the standard: a. Executive Director created an automatically generated daily alarm history report which the monitoring system e-mails to the Executive Director, Resident Care Director, and Assistant Care Director each day. b. Executive Director created an audit tool which the Resident Care Director or Assistant Care Director will complete daily to ensure review of the alarm history report. 2. Measures implemented to prevent non-compliance from occurring again: a. Executive Director created an automatically generated daily alarm history report which the monitoring system e-mails to the Executive Director, Resident Care Director, and Assistant Care Director each day. b. Executive Director created an audit tool which the Resident Care Director or Assistant Care Director will complete daily to ensure review of the alarm history report. The Resident Care Director or Assistant Care Director will investigate excessive response times, reconcile discrepancies or address with staff, and document accordingly. c. The Resident Care Director and Assistant Care Director will submit completed audit tools to the Executive Director for review. 3. Individuals responsible for implementing steps taken to correct non-compliance with the standard, measures taken to prevent non-compliance from occurring again, and monitoring preventative measures: a. Alicia Doyle, Assistant Care Director b. Rebecca Pierce, Resident Care Director c. Maureen Davis, Executive Director
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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