QA Investigation Results

Pennsylvania Department of Health
BRYN MAWR HOSPITAL, THE
Health Inspection Results
BRYN MAWR HOSPITAL, THE
Health Inspection Results For:


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Initial Comments:

This report is the result of a 5100 State survey conducted on April 24, 2019, and completed on April 29, 2019, at Bryn Mawr Hospital. It was determined the facility was not in compliance with the requirements of the Pennsylvania Department of Health's Rules and Regulations for Hospitals, 28 Pa Code, Part IV, Subparts A and B, November 1987, as amended June 1998.









Plan of Correction:




109.31 LICENSURE
NURSING CARE PLANS

Name - Component - 00
109.31 Principle

There shall be evidence that the
nursing service provides safe,
efficient, and therapeutically
effective nursing care through the
planning of the care of each inpatient
and the effective implementation of
nursing care plans. In any case, where
it is determined that a nursing care
plan is not necessary, that decision
shall be documented in the medical
record.

Observations:
Based on review of facility policy, medical record (MR) and interview with staff (EMP), it was determined the facility failed to follow its adopted policy and failed to develop a Lactation Care Plan for one of one medical record reviewed (MR1).

Findings include:

Review of facility policy "Clinical Assessment, Documentation and Care Planning Guidelines" approved February 26, 2019, revealed "B. Care Planning Process: 1. Each patient will have a written Plan of Care that is appropriative to their specific needs ...The care plan is initiated upon admission and individualized within 24 hours... 2. The plan is individualized/revised based on ongoing assessment findings, the patient's response to treatment/interventions, and evaluation of progress toward outcomes. ...3. The Inter-professional team is accountable for the coordination of the Patient Plan of Care and its ongoing additions and revision based on identified needs, per professional scope of practice. A registered nurse will determine the patient's need for nursing care based on the initial nursing assessment. ...Education Activity:... B. A learning needs assessment for each patient will be performed that includes: ...4. Physical or cognitive limitations; and 5. Barriers to communication. C. Document education provided to learner(s) using methods identified in the learning assessment. Document learners, readiness, method, and response to education provided."

Review of MR1 revealed a written physician order dated April 22, 2019, at 11:24 AM "Lactation Consultant, Order for Pump once each shift."Further review of MR1 revealed no evidence of documentation that a Lactation Plan of Care was developed for MR1. In addition, MR1 contained no evidence of documentation of a learning needs assessment and documentation of Lactation Education .

Review of MR1 revealed a nursing note written by EMP3 dated April 24, 2019, at 3:01 PM, "[MR1] did pump and dump at 11:10 AM and finished around 11:25 AM."

An interview conducted on April 24, 2019, at approximately 1:45 PM with EMP1 confirmed a Plan of Care for Lactation had not been developed for MR1. EMP1 stated "A Plan of Care for Lactation was not developed for this patient and there is no documentation in the medical record that the patient received a learning needs assessment and was provided with lactation education, therefore we are not compliant with our policy."
































Plan of Correction:

Focus Plan of Care
Behavioral Health Unit (BHU) staff will follow the Main Line Health policy "Clinical Assessment, Documentation, and Care Planning Guidelines", approved February 26, 2019. The policy calls for an individualized plan of care that is specific to the patient's needs, documentation of the patient's response to treatment/interventions. The plan of care will be updated based on patient needs. Patients in the BHU may have a co-occurring medical diagnosis in addition to the behavioral health diagnosis. The lactating BHU patient did not have a care plan that reflected the medical diagnosis/condition.
1. All patients in the BHU will have an individualized plan of care that reflects current diagnosis, treatment and response to treatment.
2. The BHU nurse manager will consult with the obstetrics nurse manager and nurse educater to develop a guideline for BHU patients who are lactating. When a BHU patient is lactating following will occur:
a. The Bryn Mawr Hospital (BMH) lactation consultant will be notified.
b. The lactation consultant will see the patient to determine the patient's ability to pump breast milk, if pumping recommended provide a breast pump for patient.
c. If pumping the patient will have 1:1 direct, in-person observation to maintained patient safety.
d. The lactation consultant will provide education to the patient regarding pumping, and breast assessment. The lactation consultant will document education and patient's response to education.
e. The provider will determine suitability of breast milk for storage vs discarding based on patient's condition and medication profile.
3. The care team will be notified that the patient is lactating during daily rounds
4. Documentation of the patient's response to lactation will be documented in the care plan
5. Lactation status and patient's response to lactation will be added to the treatment plan
6. A Job aid will be developed for staff of the BHU to consult when they have a patient who is lactating.
7. Staff will be educated on the above process. Education will be completed by 6/28/19
8. Compliance with appropriateness of care plans will be the responsibility of the BHU nurse manager. Care plans will be audited for appropriateness for 30 days. Compliance will be determined by the following:
a. Addition of co-occurring medical diagnosis as appropriate
b. When the patient is lactating the process as outlined above in #2 will be followed.
c. Expected compliance is 100%.
9. Oversight of the action plan is the responsibility of the Director of Nursing for the BHU. Compliance will be reported at the Acute Inpatient Behavioral Health Unit Leadership meeting.


Learning needs assessment
Behavioral Health Unit (BHU) staff will follow the Main Line Health policy "Clinical Assessment, Documentation, and Care Planning Guidelines", approved February 26, 2019. The policy calls for a learning needs assessment for each patient. Patient education will be completed based on the learning needs assessment and on topics identified in the plan of care.
1. All patients in the BHU will have a learning needs assessment completed upon admission according to policy.
2. Patient education will be documented. Educational topics will be driven by the plan of care and be provided in a manner that is consistent with the learning needs assessment.
3. Documentation of the learning needs assessment and patient education is the responsibility of the BHU nurse manager.
4. Compliance with required documentation will occur for 30 days. Compliance will be determined by the following:
a. Each new admission will have a learning needs assessment documented
b. Each patient will have education documented based on needs identified in care planning process
5. Oversight of the action plan is the responsibility of the Director of Nursing for the BHU. Compliance will be reported at the Acute Inpatient Behavioral Health Unit Leadership meeting.



147.2 LICENSURE
MAINTENANCE OF SAFETY & SANITATION

Name - Component - 00
147.2 Maintenance of safety and sanitation

The hospital shall be equipped, operated, and maintained so as to sustain its safe and sanitary characteristics and to minimize all health hazards in the hospital, for the protection of both patients and employes.

Observations:

Based on observation, and interview with staff (EMP), it was determined the facility failed to maintain a safe and sanitary environment in the Behavioral Health Unit.

Findings include:

An observational tour of the Behavioral Health Unit on April 24, 2019, at 2:50 PM with EMP1 and EMP2 revealed the following:

Observation of room 003 revealed a greenish-white calcium substance covering the shower head in the bathroom. Further observation revealed the cove base molding at the head of the bed was unsecured from the wall, a patient safety risk for potential ligature.

Observation of room 005 revealed peeling wall paint. Further observation revealed a greenish-white calcium substance covering the shower head in the bathroom.

Observation of Rooms 003 and 017 revealed an unsecured ceiling light lenses, a patient safety risk for potential ligature.

Observation of the Pantry revealed dust and grime covering the countertop behind the ice machine and covering the inside and outside of the pantry cabinets.

An interview conducted on April 24, 2019, at 3:50 PM with EMP1 and EMP2 confirmed the greenish-white calcium substance covering the shower heads in the bathrooms of rooms 003 and 005, the unsecured ceiling light lenses in rooms 003 and 017 and the thick gray matter which EMP2 identified as dust and grime covering the countertop behind the ice machine and covering the inside and outside of the pantry cabinets. EMP2 confirmed the unsecured cove basing molding in room 003 and the unsecured ceiling light lenses was a patient safety risk for potential ligature.










































































Plan of Correction:

An approved Plan of Correction is not on file.


Initial Comments:

This report is the result of a Department of Human Services, Chapter 5100 Mental Health Procedures Act Survey conducted on April 24, 2019, and completed on April 29, 2019, at Bryn Mawr Hospital. It was determined the facility was not in compliance with requirements of the Chapter 5100 Mental Health regulations.






Plan of Correction:




5100.54 Article I V (a-f) REQUIREMENT
Provision for Treatment

Name - Component - 00
I. PSYCHIATRIC TREATMENT

Provision for Treatment
Article IV - Right to a Humane Physical and Psychological Environment
(a) Treated humanely
(b) Positive self-image
(1) own clothing
(2) providing clothing
(3)(4) provision for personal hygiene items
(c) Living facilities
(d) Diet
(e) Sanitary facilities
(f) Activities/Recreation

Adequate treatment includes such accommodations as diet, heat, light, sanitary facilities, clothing, recreation, education and medical care as necessary to maintain a decent, safe and healthful living conditions

Observations:

Based on observation, and interview with staff (EMP), it was determined the facility failed to maintain a safe and sanitary environment in the Behavioral Health Unit.

Findings include:

An observational tour of the Behavioral Health Unit on April 24, 2019, at 2:50 PM with EMP1 and EMP2 revealed the following:

Observation of room 003 revealed a greenish-white calcium substance covering the shower head in the bathroom. Further observation revealed the cove base molding at the head of the bed was unsecured from the wall, a patient safety risk for potential ligature.

Observation of room 005 revealed peeling wall paint. Further observation revealed a greenish-white calcium substance covering the shower head in the bathroom.

Observation of Rooms 003 and 017 revealed an unsecured ceiling light lenses, a patient safety risk for potential ligature.

Observation of the Pantry revealed dust and grime covering the countertop behind the ice machine and covering the inside and outside of the pantry cabinets.

An interview conducted on April 24, 2019, at 3:50 PM with EMP1 and EMP2 confirmed the greenish-white calcium substance covering the shower heads in the bathrooms of rooms 003 and 005, the unsecured ceiling light lenses in rooms 003 and 017 and the thick gray matter which EMP2 identified as dust and grime covering the countertop behind the ice machine and covering the inside and outside of the pantry cabinets. EMP2 confirmed the unsecured cove basing molding in room 003 and the unsecured ceiling light lenses was a patient safety risk for potential ligature.


































































































Plan of Correction:

An approved Plan of Correction is not on file.


5100.15 (2) REQUIREMENT
Treatment Plan Content and Availability

Name - Component - 00
5100.15 CONTENTS OF TREATMENT PLANS

(a) A comprehensive individualized plan of treatment shall:
(2) Be based upon diagnostic evaluation which includes examination of the medical, psychological, social, cultural, behavioral, familial, educational, vocational, and developmental aspects of the patients situation.

Observations:


Based on review of facility policy, medical record (MR) and interview with staff (EMP), it was determined the facility failed to follow its adopted policy and failed to develop a Lactation Care Plan for one of one medical record reviewed (MR1).

Findings include:

Review of facility policy "Clinical Assessment, Documentation and Care Planning Guidelines" approved February 26, 2019, revealed "B. Care Planning Process: 1. Each patient will have a written Plan of Care that is appropriative to their specific needs ...The care plan is initiated upon admission and individualized within 24 hours... 2. The plan is individualized/revised based on ongoing assessment findings, the patient's response to treatment/interventions, and evaluation of progress toward outcomes. ...3. The Inter-professional team is accountable for the coordination of the Patient Plan of Care and its ongoing additions and revision based on identified needs, per professional scope of practice. A registered nurse will determine the patient's need for nursing care based on the initial nursing assessment. ...Education Activity:... B. A learning needs assessment for each patient will be performed that includes: ...4. Physical or cognitive limitations; and 5. Barriers to communication. C. Document education provided to learner(s) using methods identified in the learning assessment. Document learners, readiness, method, and response to education provided."

Review of MR1 revealed a written physician order dated April 22, 2019, at 11:24 AM "Lactation Consultant, Order for Pump once each shift."Further review of MR1 revealed no evidence of documentation that a Lactation Plan of Care was developed for MR1. In addition, MR1 contained no evidence of documentation of a learning needs assessment and documentation of Lactation Education .

Review of MR1 revealed a nursing note written by EMP3 dated April 24, 2019, at 3:01 PM, "[MR1] did pump and dump at 11:10 AM and finished around 11:25 AM."

An interview conducted on April 24, 2019, at approximately 1:45 PM with EMP1 confirmed a Plan of Care for Lactation had not been developed for MR1. EMP1 stated "A Plan of Care for Lactation was not developed for this patient and there is no documentation in the medical record that the patient received a learning needs assessment and was provided with lactation education, therefore we are not compliant with our policy."














































Plan of Correction:

The contents of the treatment plan will be as outlined in the BHU policy," Psychiatry Treatment Plans, Interdisciplinary". The policy is based on the PA DOH regulation 5100.15 (2)
The comprehensive interdisciplinary treatment plan is an individualized treatment plan that meets the medical, psychological, social, cultural, behavioral, familial, educational, vocational, and developmental aspects of the patient's situation. The comprehensive treatment plan is used to plan and communicate treatment, and response to treatment. The lactating BHU patient did not have a treatment plan that reflected the medical condition.
1. All patients in the BHU will have a comprehensive interdisciplinary, individualized treatment plan.
2. The medical condition will be noted on the treatment plan. The treatment plan will reflect patient's response to the plan for care of the medical condition. The treatment plan will reflect the interdisciplinary team's evaluation of the current condition and the patient's response to the treatment plan.
3. Staff will be educated on the above process. Education will be completed by 6/28/19
4. Compliance with appropriateness of treatment plans will be the responsibility of the BHU nurse manager. Treatment plans will be audited for appropriateness for 30 days by the nurse manager or designee. Compliance will be determined by the following:
a. Completeness of the treatment plan as evidenced by documentation of any co-occurring medical condition.
b. Expected compliance is 100%.
5. Oversight of the action plan is the responsibility of the Director of Nursing for the BHU. Compliance will be reported at the Acute Inpatient Behavioral Health Unit Leadership meeting.



5100.72 (a)(b)(1-3)(c)(1-2)(d)(1-3) REQUIREMENT
Applications

Name - Component - 00
VOLUNTARY TREATMENT

5100.72 APPLICATIONS

(a) Written application for voluntary inpatient treatment is made on form MH-781 issued by the department of Public Welfare (DPW).
(b) A State-operated facility shall not accept an application for voluntary inpatient treatment for persons not currently in the facility unless:
(1) There is concurrence on an individual case basis given by the administrator.
(2) There is a preexisting agreement of waiver approved by the Deputy Secretary of Mental Health between the State facility and the Administrator which designates that facility as the only provider of inpatient services of the county program.
(3) There is a preexisting letter of agreement approved by the Deputy Secretary of Mental Health between the State facility and the Administrator which designated the state facility as:
(i) A substitute provider of inpatient services on a temporary basis when an emergency need arises and there are no other appropriate approved facilities available or;
(ii) A provider of specialized forensic inpatient services when a need for security arises.
(4) Such letter of agreement shall define the nature of security to be available and the responsibilities of both the State facility and the administrator.
(c) When application is made to an approved facility, the director of the facility shall:
(1) Be responsible for insuring that a preliminary evaluation of the applicant is conducted in order to establish the necessity and appropriateness of outpatient services or partial hospitalization or inpatient hospitalization service for the individual applicant. The preliminary evaluation shall be done in the least restrictive setting possible. The results of the preliminary evaluation shall be set forth on Form MH-781-A issued by the Department.
(2) Promptly notify the administrator if the applicant's treatment will involve mental health/mental retardation (MH/MR) funding.
(d) When application is made to the administrator:
(1) The administrator shall designate an approved facility which shall conduct a preliminary evaluation of the applicant in order to establish the necessity and appropriateness of outpatient services or partial hospitalization for the individual applicant.
(2) The designated facility shall immediately upon its completion of the preliminary evaluation , notify the administrator of its finding and recommendations.
(3) Upon receipt of the report, the administrator shall review the report and when necessary, designate an approved appropriate facility for the recommended treatment of the individual applicant.


Observations:

Based on review of facility policy, document, medical record (MR), and interview with staff (EMP), it was determined that the facility failed to ensure the date of admission and the signatures of the patient and physician obtaining the consent was dated for one of one medical record (MR1).

Findings include:

Review of facility policy "Informed Consent" last revised October 2018 revealed " II. The Informed Consent Process: Documentation...D. The agreement of the patient to undergo the proposed treatment or procedure must be documented in the medical record using the Consent Form, unless otherwise specified in this policy. Where required by law, applicable consent forms must be used...1. All applicable blank lines must be completed on the Consent Form.

Review on April 24, 2019, of MR2, admitted on April 10, 2019, through the facility's emergency department (ED) to the inpatient Behavioral Unit utilizing the required voluntary form (781) revealed the form did not contain the Admission Date and the dated signatures of MR2 and EMP4, a physician. Further review revealed the form did provide lines to insert the date of admission and a line to insert the date next to the signatures of MR2 and EMP4, the physician.

An interview conducted on April 24, 2019, at 4:35 PM with EMP1 and EMP2 confirmed the" Consent For Voluntary Inpatient Treatment" form for MR2 did not contain an admission date. EMP2 stated "The lack of an admission date on the form in addition to the undated signatures of the physician and the patient on the form does not allow me to confirm whether this voluntary consent form represents the patient's admission for April 10, 2019. The facility was unable to produce a completed voluntary inpatient consent form for MR2 with an admission date of April 10, 2019.














Plan of Correction:

An approved Plan of Correction is not on file.