Nursing Investigation Results -

Pennsylvania Department of Health
BRYN MAWR VILLAGE
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
BRYN MAWR VILLAGE
Inspection Results For:

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BRYN MAWR VILLAGE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Survey in response to a complaint, completed on June 16, 2022, it was determined that Bryn Mawr Village, was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.




 Plan of Correction:


483.95(c)(1)-(3) REQUIREMENT Abuse, Neglect, and Exploitation Training:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
483.95(c) Abuse, neglect, and exploitation.
In addition to the freedom from abuse, neglect, and exploitation requirements in 483.12, facilities must also provide training to their staff that at a minimum educates staff on-

483.95(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at 483.12.

483.95(c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property

483.95(c)(3) Dementia management and resident abuse prevention.
Observations:

Based on interviews with facility staff and a review of facility policy and documentation, it was determined the facility failed to ensure that abuse training was being completed for new staff and annually for current staff.

Findings include:

A review of the undated facility policy and procedure titled, Abuse Prevention Program, indicated, "Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior."

An interview with the Director of Nursing (DON), Employee E1, after a request for new hire abuse training records, revealed that he could not locate this training, and that to his knowledge this training has not been done since he started working at the facility on February 21, 2022. After a request for records of ongoing or annual staff training for Abuse, the DON confirmed that there were no records to review.

The facility failed to ensure that abuse training was being completed for new hires and annually for all staff as required.


Pa. Code: 201.14(a)(b) Responsibility of Licensee

Pa. Code: 201.18(a)(b)(1)(3) Management

Pa. Code: 201.19 Personnel Policies and Procedures

Pa. Code: 201.20(a)(b)(c)(d) Staff Development




 Plan of Correction - To be completed: 08/15/2022

Employee E1 was educated on the facilities abuse policy.
NHA DON and HR Director will be educated on the requirement for all employees to be trained on facilities abuse policy annually and upon hire.
The facility will provide an abuse training for all employees on the facilities abuse policy.
NHA or designee will conduct on audit monthly times 3 months to ensure all new hires were educated in abuse policy upon hire. Findings will be presented at QAPI to make recommendations.

483.90(i) REQUIREMENT Safe/Functional/Sanitary/Comfortable Environ: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.
483.90(i) Other Environmental Conditions
The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.
Observations:

Based on observations and interviews with residents and staff, it was determined that the facility failed to maintain a clean, and comfortable environment on one of two nursing units. (East wing)

Findings include:

Observations during a tour of the facility at 9:30 am on June 16, 2022, revealed the following areas were observed in the East wing:

There was a strong urine odor in the main hall of the East wing nursing unit. A container was observed in the hall where soiled briefs were disposed. A strong urine odor permeated the East wing.

Three of six residents (R4, R7 and R8) interviewed during a tour of the facility at 9:30 am on June 16, 2022, had complaints of foul urine and fecal odors in the facility.

One of three visitors (V1) interviewed during a tour of the facility at 9:30 am on June 16, 2022, had complaints of foul urine and fecal odors in the facility.

28 Pa. Code 201.18(3) Management

28 Pa. Code 207.2(a) Administrator's responsibility




 Plan of Correction - To be completed: 08/15/2022

The main hall of the East wing unit was cleaned and is odor free. The soiled briefs were disposed of properly.
Housekeeping and nursing staff will be educated on making certain that a clean and comfortable environment is provided and maintained. Staff will be educated to dispose of waste as per facility policy and that if there is an area that is not clean to notify housekeeping.
The NHA or designee will conduct an audit weekly times 4 weeks then bi-weekly times 2 months to ensure that a clean and comfortable environment is being provided. Findings will be reported at QAPI to make recommendations.

35 P. S. 448.809b LICENSURE Photo Id Reg:State only Deficiency.
(1) The photo identification tag shall include a recent photograph of the employee, the employee's FIRST name, the employee's title and the name of the health care facility or employment agency.

(2) The title of the employee shall be as large as possible in block type and shall occupy a one-half inch tall strip as close as practicable to the bottom edge of the badge.

(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title " Physician. "
(ii) A Doctor of Osteopathy shall have the title " Physician. "
(iii) A Registered Nurse shall have the title " Registered Nurse. "
(iv) A Licensed Practical Nurse shall have the title " Licensed Practical Nurse. "
(v) Abbreviated titles may be used when the title indicates licensure or certification by a Commonwealth agency.

(4)A notation, marker or indicator included on an identification badge that differentiates employees with the same first name is considered acceptable in lieu of displaying an employee's last name.


Observations:

Based on observation and staff interview, it was determined that the facility failed to ensure that three of eight employees interviewed had a photo identification tag. (Employee E3, Employee E4, and Employee E6)

Findings include:

Interview conducted on June 16, 2022, at approximately 9:30 a.m. with the nursing assistant, Employee E6, revealed that Employee E6 did not have a photo identification tag on her possession. Employee E6 indicated during interview that she had been working at the facility for nineteen years, but when the new company took over nine months ago they did not receive a photo identification tag.

Interview conducted on June 16, 2022, at approximately 9:32 a.m. with the nursing assistant, Employee E3, revealed that Employee E3 did not have a photo identification tag on her possession. She indicated that she did not have a photo identification tag.

Interview conducted on June 16, 2022, at approximately 9:35 a.m. with the agency nursing assistant, Employee E4, revealed that Employee E4 did not have a photo identification tag on her possession. She indicated that she had an agency identification badge in her purse.

Interview with the Director of Nursing, Employee E1, conducted on June 16, 2022, at approximately 11:30 a.m. confirmed that the staff above did not have a photo identification tag.



 Plan of Correction - To be completed: 08/15/2022

Employees E3, E4 & E6 were educated on the requirement to have a photo identification tag.
All employees will be educated on the requirement to wear a proper photo ID badge and will be provided with one if they do not have one.
NHA or designee will conduit an audit weekly times 4 weeks then bi-weekly time 2 months to ensure that all staff are wearing a proper


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