Surry Community Health Center by Harborview

In the surveyor’s words

From the most serious findings on record at Surry Community Health Center by Harborview, in the surveyor’s own words.

• Immediate jeopardy, patternF585Mar 27, 2024

  Based on record review and Resident, Resident Representative (RR) and staff interviews the facility failed to implement grievance policy and procedures when a resident (Resident #21) reported on 11/30/23 the facility was running out of her Methadone. The Director of Nursing (DON) was assigned the grievance and on 12/01/23 confirmed Resident #21 had Methadone in the medication cart, and it had been documented as administered. The DON did not interview the resident or determine if there had been any supply issues with Resident #21's Methadone. Due to the lack of investigation this problem continued. Resident #21 reported she experienced terrible/awful pain of greater than ten on a scale of 1 to 10. […]

• Immediate jeopardy, patternF602Mar 27, 2024

  Based on record review and family, Pharmacist, Medical Director (MD), Physician Assistant (PA), former staff, and current staff interviews the facility failed to protect a resident (Resident #21) from misappropriation of controlled substances by facility staff. Resident #21 reported starting the end of November 2023 she was told by Medication Aide (MA) #3 the facility had run out of her Methadone (analgesic opioid agonist), or MA #3 would tell her that she would bring her pain medication and never return during the night shift (7:00 pm to 7:00 am). Review of Resident #21's Medication Administration Record (MAR) for 11/2023 through 02/14/2024 revealed Resident #21's Methadone was signed out as administered by Medication Aide (MA) #3 every night shift she was assigned to the resident. […]

• Immediate jeopardy, patternF607Mar 27, 2024

  Based on record review and staff interviews the facility failed to implement their abuse, neglect, and exploitation policy in the areas of protection, reporting, and investigating allegations of abusive actions perpetrated by staff toward residents. On 3/10/24 Medication Aide (MA) #1 and Nurse Aide (NA) #2 placed Resident #98 and Resident #305 in involuntary seclusion and on 3/12/24 Nurse Aide (NA) #1 utilized a physical restraint for Resident #15 that was not required to treat the resident's medical symptoms. Following the incidents, MA #1 and NA #1 were allowed to continue working direct care resident assignments. Additionally, the facility failed to investigate the allegations and to report the allegations to the state agency, law enforcement, and Adult Protective Services. […]

• Immediate jeopardy, patternF697Mar 27, 2024

  Based on observation, record review and resident, resident representative, Pharmacy, Medical Director (MD), Physician Assistant (PA), and staff interviews, the facility failed to address a resident's pain (Resident #21) after repeated reports to staff that she had not received her pain medications during the night shift (7:00 AM to 7:00 PM). Resident #21 reported starting the end of November 2023 she was told by Medication Aide (MA) #3 the facility had run out of her Methadone (analgesic opioid agonist), or MA #3 would tell her that she would bring her pain medication and never return during the night shift. Resident #21 informed the PA on 12/12/23 that her pain medications were not being given to her. […]

• Immediate jeopardy, patternF755Mar 27, 2024

  Based on record review and Resident, Pharmacist and staff interviews the facility failed to have systems in place for accurately receiving and reconciling controlled medications from the pharmacy. On 10/23/23 a possible drug diversion by Nurse #5 was reported to administration by Nurse #4. An effective investigation was not conducted which put other residents at risk for loss or diversion of controlled medications. In addition, a discrepancy was identified between the pharmacy dispensary reports and the controlled medication sign-out sheets for Resident #21's Methadone received by Medication Aide (MA) #3 on 10/13/23 and 1/16/24. […]