Vcu Health Children's Services at Brook Road

In the surveyor’s words

From the most serious findings on record at Vcu Health Children's Services at Brook Road, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF656Apr 20, 2023

  Based on observation, staff interview, and clinical record review, it was determined that the facility staff failed to develop and/or implement a care plan for five of 14 residents in the survey sample, Residents #19, #16, #29, #30, and #10. The findings include: 1. For Resident #19 (R19), the facility staff failed to implement the care plan for the use of bilateral (both left and right) AFOs (ankle/foot orthoses-which are devices for positioning of the ankle/foot). On 4/19/23 at 9:53 a.m., R19 was sitting in a wheelchair in the facility school room. R19 did not have any positioning devices on their feet or ankles. RN (registered nurse) #2 stated the resident was not wearing an AFO at that moment, and that the staff would put the AFOs on if the resident was positioned in a stander. […]

• No harm, potential for more than minimal, patternF756Apr 20, 2023

  Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to develop a Medication Regimen Review policy that included required time frames for pharmacist's review and physician's response to the pharmacist's recommendations, for five of 14 residents in the survey sample; Residents #22, #8, #10, #30, and #29. The findings include: 1. For Resident #22 the facility staff failed to ensure the medication regimen review policy contained required time frames for pharmacist's review and physician's response. A review of the clinical record revealed all required monthly medication regimen reviews and no concerns were identified. […]

• No harm, potential for more than minimal, isolatedF657Apr 20, 2023

  Based on staff interview and clinical record review, it was determined that the facility staff failed to review and revise the comprehensive care plan for two of 14 residents in the survey sample, Residents #7 and 22. The findings include: 1. For Resident #7 (R7), the facility staff failed to revise the care plan when the resident developed a pressure ulcer. A review of R7's clinical record revealed the resident was receiving treatment for a pressure ulcer. The record contained the following physician's order: Sodium Hypochlorous Acid (Vashe Wound Cleanser) 0.333% Once per day [for pressure ulcer] on Monday, Wednesday, Friday. […]

• No harm, potential for more than minimal, isolatedF688Apr 20, 2023

  Based on observation, staff interview, and clinical record review, the facility staff failed to apply orthotic devices as ordered for two of 14 residents in the survey sample, Residents #19 and #16. The findings include: 1. For Resident #19 (R19), the facility staff failed to apply bilateral (both left and right) AFOs (ankle/foot orthoses) (devices for positioning of the ankle/foot) when the resident was out of bed. On 4/19/23 at 9:53 a.m., R19 was sitting in a wheelchair in the facility school room. R19 did not have any positioning devices on his feet or ankles. RN (registered nurse) #2 stated the resident was not wearing an AFO at that moment, and that the staff would put the AFOs on if the resident was positioned in a stander. […]

• No harm, potential for minimal, widespreadF732Apr 20, 2023

  Based on observation, staff interview, and facility document review, it was determined that the facility staff failed to post the required staff posting for 33 of 33 days reviewed. The findings include: On 4/19/23 at approximately 10:30 AM a tour of the facility was conducted; the required staff posting for the shift was not observed posted. The facility document that was provided as the daily staff posting was reviewed for the period of 3/18/23 through 4/20/23. The document was a combined document of daily staff posting, as-worked schedule, and staff assignments. The document contained the date, shift, and census but it also contained resident names and did not contain staff hours. On 4/19/23 at 10:45 AM an interview was conducted with RN #2 (Registered Nurse) the unit manager. […]