22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 EMERGENCY PREPAREDNESS
Comments:
Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/29/2024 9:15am until 3:30pm 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 regarding allegations in the area(s) of: Administration and administrative services, personnel, resident care and related services and emergency preparedness.
Number of residents present at the facility at the beginning of the inspection: 77 Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation supported some, but not all of the self-report; area(s) of non-compliance with standard(s) or law were: Administration and administrative services
A violation notice was 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Based on facility documentation and resident and staff interviews, the facility failed to ensure compliance with the facility?s own policies and procedures for vehicle safety program.
EVIDENCE:
1. In an interview with resident 1 on 08/29/2024, resident 1 explained that during a trip to a doctor?s appointment, her wheelchair fell over while she was sitting in it on the wheelchair van and that she had hit her head on the floor of the van. Resident 1 expressed that the van driver pulled over to check on her and then proceeded to drive her to the Hospital where staff assisted her out of the wheelchair van and took her in to be evaluated. Resident 1 indicated that she had a seat belt around her waist that kept her in the wheelchair when it tipped over but could not remember anything about safety straps that secure the wheelchair itself to the floor of the wheelchair van.
2. In an interview with staff person 1 on 08/29/2024, staff person 1 expressed that they were transporting resident 1 to a doctor?s appointment on 04/16/2024. Staff person 1 indicated that they had started to take a turn when they heard resident 1 scream out. Staff person 1 explained that they looked back in the van and saw that resident 1?s wheelchair was tilted to one side. Staff person 1 said that as they completed the turn, resident 1?s wheelchair fell over. Staff person 1 explained that they pulled over to check on resident 1 but was unable to lift resident 1 so they proceeded on to the local emergency room for evaluation. When asked by the licensing inspector (LI) about the safety belts on the wheelchair van, staff person 1 expressed that they had placed the safety belts on the wheels of resident 1?s wheelchair and not on the wheelchair frame. Staff person 1 also explained that they had not tightened the safety belts after hooking them to the front wheels of the wheelchair.
3. In an incident report received by the LI on 04/22/2024, documentation is noted that ?the employee failed to secure resident in wheelchair van per the proper techniques and protocols, employee attached wheelchair straps to the wheel of the wheelchair rather than the frame of the wheelchair?.
4. The facility Vehicle Safety Program revised in January 2024 has documentation on page 8 under vehicle safety belts that ?The Driver and ALL OCCUPANTS are required to wear safety belts when operating or riding in a Motor Vehicle. The Driver is responsible to ensure all passengers are wearing their safety belts?. Documentation on page 12 under Transporting Residents has that ?Before departure, please ensure that anu and all residents in a wheelchair or motorized scooter are appropriately secured and strapped in according to the vehicle?s manufacturer standards. Also please be assured before departure that all resident?s seat belts are appropriately fastened and secure?.
Plan of Correction:
What has been done to correct-Corrective Action was provided to Staff Person 1 with instruction to complete training related to safe transport and securing residents during transportation. On 4/18/24 she completed training ?Providing Safe Transportation?. Along with this training she also completed physical demonstration to ED on appropriate management of residents during transportation to include securing resident to assure safety.
How will recurrence be prevented-a second person checks behind the person securing the resident and wheelchair.
Person responsible-ED, programing assistant, or designee.
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.
Find this content at:
http://www.dss.virginia.gov/facility/search/alf.cgi