INITIAL COMMENTS
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This report is a result of a complaint investigation conducted on December 2, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the complaint investigation, the allegations made against Cove Forge Behavioral Health System at Williamsburg were not substantiated, however additional areas of non- compliance were noted during the investigation. A plan of correction must be submitted by December 24, 2010.
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Plan of Correction
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709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
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Observations
Based on the review of one client record, agency policy and an interview with the nursing director and nursing supervisor, the facility failed to insure that medication orders were signed by the prescribing physician within 24 hours of the order.
The findings include:
An unannounced, onsite complaint investigation was conducted on December 2 , 2010. One client record was reviewed. The agency policy on medication administration was reviewed and two nursing staff were interviewed, the nursing director and the nursing supervisor.
Record #1 - This client was admitted on 11/10/10 and determined to be inappropriate for placement at the facility due to extensive medical issues. The attending physician ordered medications for this individual on the order sheet in the client record on 11/11/10. At the time of the record review on 12/2/10, the orders had not been signed by the physician. Agency policy MM08 states that the required elements of a complete medication order are to include the physician signature.
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Plan of Correction
709.32. Medication Control Verbal medication orders are accepted and put into writing and signed 24 hours thereafter by the prescribing physician.
The Assistant Administrator is responsible for informing the physicians of the deficiency noted. This was done verbally and in writing on 12/5/10.
The Medical Records Coordinator in cooperation with the Nursing Unit Coordinator will develop a plan to insure that orders are signed within 24 hours.
The Medical Records Coordinator will meet with the Nursing Unit Coordinator and Medical Director to review the plan and initiate the plan of correction on 12/15/10. Random sampling of records will be audited monthly by the Nursing Unit Coordinator to ensure compliance.
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709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on the review of one client record and an interview with the nursing director and nursing supervisor, the facility failed to insure that the client's physical examination was co-signed by the attending physician.
The findings include:
An unannounced, onsite complaint investigation was conducted on December 2 , 2010. One client record was reviewed. The agency policy on medication administration was reviewed and two nursing staff were interviewed, the nursing director and the nursing supervisor.
Client record #1 - This client was admitted on 11/10/10 and determined to be inappropriate for placement at the facility due to extensive medical issues. The Physician Assistant completed the physical examination for this individual on 11/11/10. At the time of the client record review on 12/2/10, the physical examination document had not been co-signed by the physician. Nursing staff acknowledged that the physician is required to sign the physicals which are done by the Physician Assistant.
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Plan of Correction
709. 51. Intake and admission. Intake procedures will include documentation of physical examination.
The Assistant Administrator is responsible for informing the physicians of the deficiency noted. This was done verbally and in writing on 12/5/10.
The Medical Records Coordinator in cooperation with the Nursing Unit Coordinator will develop a plan to insure that the clients' physical examination is co-signed by the attending physician.
The Medical Records Coordinator will meet with the Nursing Unit Coordinator and Medical Director to review the plan and initiate the plan of correction on 12/15/10. Random sampling of records will be audited monthly by the Nursing Unit Coordinator to ensure compliance.
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