Pennsylvania Department of Health
BRIGHTON REHABILITATION AND WELLNESS CENTER
Patient Care Inspection Results

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BRIGHTON REHABILITATION AND WELLNESS CENTER
Inspection Results For:

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BRIGHTON REHABILITATION AND WELLNESS CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an Abbreviated survey in response to five complaints completed on April 10, 2024, it was determined that Brighton Rehabilitation and Wellness Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


483.10(h)(1)-(3)(i)(ii) REQUIREMENT Personal Privacy/Confidentiality of Records:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(h) Privacy and Confidentiality.
The resident has a right to personal privacy and confidentiality of his or her personal and medical records.

483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.

483.10(h)(3) The resident has a right to secure and confidential personal and medical records.
(i) The resident has the right to refuse the release of personal and medical records except as provided at 483.70(i)(2) or other applicable federal or state laws.
(ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law.
Observations:
Based on review of facility policy, observation, and staff interview it was determined that the facility failed to maintain the confidentiality of a resident's medical information on one of three nursing units (Third Floor Main).

Findings include:

Review of the facility policy "HIPAA- Health Insurance Portability and Accounting Act)" last reviewed on 10/1/23, indicated that the facility will keep information regarding a resident's health private and confidential. This includes information on paper, faxed, on computer and spoken aloud.

During an observation on 4/10/24, at 11:01 a.m. the Medication Cart on the Third Floor Main hallway floor was left unattended with the computer screen open with identifiable information, so that any passerby could see resident personal and confidential information.

During an interview on 4/10/24, at 11:01 a.m. Infection Control Director Employee E3 confirmed that the facility failed to maintain resident identifiable personal and medical information in a confidential manner.


28 Pa. code: 211.5(b) Clinical records.

28 Pa. Code: 201.29(i) Resident Rights

28 Pa. Code: 211.12(d)(3) Nursing Services


 Plan of Correction - To be completed: 05/08/2024

1. Laptop on medication cart on 3 main was closed, nurse was reeducated on HIPAA compliance.
2. ADONs toured units in facility to ensure all medication laptops were locked if unattended.
3. Nursing staff will be reeducated by director of nurses/designee on HIPAA compliance.
4. Director of Nursing/designee will audit 3 units twice weekly for 2 weeks, 3 units weekly for 2 weeks and 3 units monthly for 2 months to ensure compliance with protected healthcare information.

211.1(b) LICENSURE Reportable diseases.:State only Deficiency.
(b) Cases of scabies, lice or bed bug infestations shall be reported to the appropriate Division of Nursing Care Facilities field office.
Observations:
Based on review of facility policy, resident clinical record, facility pest control documents, and staff interviews it was determined that the facility failed to report a case of bed bugs to the local State field office for one out of two sampled residents (Resident R1).

Findings include:

The facility "Report of unusual circumstances" policy last reviewed 10/1/23, indicated that unusual occurrences are reported by the facility to regulatory authorities as required by federal, state laws and local agencies. A written report will be forwarded to all appropriate authorities.

Review of Resident R1's admission record indicated she was admitted on 6/17/22.

Review of Resident R1's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 2/8/24, indicated that she had diagnoses that included dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), anxiety disorder (a medical condition creating a sense of acute fear, restlessness, and worry), diabetes (metabolic disorder impacting organ function related to glucose levels in the human body) and hyperlipidemia (elevated lipid levels within the blood). The diagnoses were current upon review.

Review of Resident R1's nurse progress note dated 3/18/24, indicated that a nurse was made aware by a nurse aide that Resident R1's room had bed bugs in it. This nurse notified the unit director and provided this nurse with orders to have nurse aide bag up Resident R1's belongings to be sent down to laundry. Unit director notified housekeeping staff to notify Pest Control.

Review of the facility pest control log for March 2024 indicated that bed bugs were observed and a treatment was provided.

Review of facility pest control invoices dated 3/19/24, indicated that bed bug elimination treatment was provided.

During an interview on 4/10/24, at 12:16 p.m. the Housekeeping supervisor/environment services stated that as per pest control log, on 3/19/24 a bed bug was found in Resident R1's room. The room was treated.

During an interview on 4/10/24, at 12:18 p.m. the Assistant Director of Nursing (ADON) confirmed that the facility failed to report a case of bed bugs involving Resident R1 to the local State field office as required.









 Plan of Correction - To be completed: 05/08/2024

1. Bedbug incident was reported to DOH via ERS, reference Event ID #999707.
2. NHA reviewed pest management logs to ensure cases of suspected bed bugs were addressed by pest management and reported as required. No additional issues identified.
3. NHA will reeducate housekeeping managers on reporting presence of suspected bedbugs to administration for timely reporting.
4. NHA/designee will audit pest management logs weekly for 1 month, then monthly for 2 months to ensure cases of suspected bedbugs are reported per regulation.


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