Pennsylvania Department of Health
BRYN MAWR EXTENDED CARE CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

BRYN MAWR EXTENDED CARE CENTER
Inspection Results For:

There are 240 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


BRYN MAWR EXTENDED CARE CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, State Licensure Survey and an Abbreviated survey in response to four complaints, completed on November 1, 2024, it was determined that Bryn Mawr Extended Care, was not in compliance with the 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:

483.25(k) REQUIREMENT Pain Management:

This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.

�483.25(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Observations:

Based on a review of clinical records, review of facility documentation, review of facility policy, review of hospital records and interviews with staff, it was determined that the facility failed to assess resident's pain and timely obtain pain medication for adequate pain management for one of 28 residents reviewed. This failure resulted in actual harm to Resident R381 whose pain to the left foot was not properly relieved and managed and continued to experience uncontrolled pain. (Resident R381).

Findings include:

Review of the facility's policy for Emergency Medication Supplies (Emergency kit) revised December 2023 stated the pharmacy may provide the facility with "Emergency Medication." Emergency medications shall be accessed by authorized facility staff when a medication is medically necessary to be administered before the next scheduled pharmacy delivery and for "New Admissions."

Review of the facility's pain management policy revised August 2024 stated the policy of this community to ensure any resident admitted to the facility is assessed for pain and/or potential for pain. A pain evaluation will occur on admission and with a significant change in condition. The evaluation will include active pain, including the type, intensity, characteristics, and frequencies, what pharmacological interventions used in the past to address the pain and the efficacy of such interventions, including use of opioids and any history of opioid use...Using the numeric pain rating scale (an 11-point scale where 0 indicates no pain and 10 indicates the worst pain imaginable) when evaluating the presence of pain.

Further review of the facility's pain policy indicates, when the pharmacological interventions are needed the effect of the medication will be documented, and "The physician will be notified of new onset of pain or a significant increase in pain as appropriate."

Review of Resident R381's clinical records revealed the resident was admitted to the hospital on October 5, 2024, when emergency services found (him/her) outside "screaming in pain," due to a chronic ulcer wound on (his/her) right ankle.

Review of the hospital's physical therapy note, dated October 11, 2024, noted the resident complained of pain, with contractures in multiple joints and limited range of motion in (resident) hips and knees with chronic right ankle deformity. Therapy notes stated the resident remained in (his/her) wheelchair 24/7 without transferring for toileting or sleeping and was unable to lay flat on (his/her) back.

Review of admission documentation revealed that Resident R381 was admitted to the facility on October 11, 2024. Resident R381 was admitted to the facility with the diagnoses of an unspecified open wound, left ankle sequela (any complication or condition as a result of a previous disease or injury), chronic leg pain, Peripheral Vascular Disease (poor circulation of the extremities) and Cellulitis (potentially serious bacterial infection that effects the deeper layers of the skin). Review of hospital medication orders revealed that the resident was ordered pain medication Oxycodone IR (immediate release) 5 milligrams by mouth every 6 hours.

Review of admission progress note dated October 12, 2024, at 2:17 a.m. Licensed Practical Nurse (LPN) Employee E9 revealed " Received resident sitting on the side of the bed complaining of pain. APAP (Acetaminophen) 975 MG (milligrams) was offered to resident and (he/she) refused stating (resident) wants (his/her) oxycodone. This writer then informed resident that its not available this second take tylenol until we're able to obtain it, resident still refused APAP."

Review of Resident R381's October 2024 Medication Administration Record (MAR) revealed that the resident was ordered on October 11, 2024, Acetaminophen 325 milligrams two tablets by mouth every 4 hours as needed for headache/pain. The resident was administered the medication on October 11, 2024, at 8:12 a.m. for a pain level of 9 on his/her right knee and left ankle.

Continued review of the MAR revealed that this was the only occasion Acetaminophen 325 milligrams was administered to the resident. There was no documented evidence that the resident's pain level was assessed on October 11, 2024, during the evening and night shifts. The next time the resident was medicated for pain was October 12, 2024, that an order was obtained for Oxycodone 5 milligrams one tablet by mouth every 6 hours for severe pain over 7/10 (pain severely scale of 0-10). The resident was administered Oxycodone 5 milligrams on October 12, 2024, at 9:55 a.m. for a pain level of 9.

Continued review of nursing notes dated October 12, 2024, at 1:15 p.m. revealed that the resident was requesting as needed Oxycodone. Licensed nurse, Employee E9 explained again that "its every 6 hours and it has only been 3 hours. Resident was offered APAP (Acetaminophen) in which he refused. The resident began to demand to see the supervisor and DON saying its every 4 hours. Supervisor explained to resident it's every 6 hours and that it's too soon to administer."

Continued review of Resident R381's clinical record revealed, approximately an hour after receiving the first dose of Oxycodone, a note written by physical therapist at 10:59 a.m. stated the resident, "Perseverates on LLE (left lower extremity) pain and states (he/her) is in 10/10 pain; nursing is aware and reports patient received pain meds this AM" ... "Pt continues to refuse any further mobility and states, 'The only therapy I want to do is jump out the window and hopefully slit my carotid on the way," when pressed regarding statement pt reports "[Resident] is in a lot of pain at this time." Nursing supervisor and charge nurse made aware of patient's statements and behaviors."

When the resident expressed to the therapist, (Resident) was in a severe pain there was no evidence the physician was notified. Instead of acknowledging the resident's pain, a late note written by the supervisor, dated October 12, 2024, documented that the therapist reported the resident with suicidal ideation and was immediately placed on a 1:1 supervision, and further stated "After that, resident did not report suicidal ideation." Continued review of the clinical record revealed the resident was "Placed on 1:1 for suicidal ideation related to pain management." The LPN, Employee E9 witness statement indicated, 'The supervisor and the Director of Nursing asked the resident to stay and 'Wait for pharmacy to deliver (his/her) meds.'

During interview with the Director of Nursing (DON) on October 31, 2024, at 2 p.m. the DON was asked why the medication "wasn't available." In addition, the delay obtaining an "authorization code," and why the emergency medication was not utilized sooner. The DON was also interviewed as to no evidence that the resident's physician was notified regarding the resident's pain. The DON had no response for not calling the physician nor waiting for the authorization number but did reply it was the weekend and staff did not want to bother the physician.

The facility failed to ensure that Resident's left foot pain was managed resulting in actual harm to Resident R381 who continued to experience uncontrolled pain.

28 Pa. Code 211.2 (d)(9)(10) Medical director

28 Pa. Code 211.10(c) Resident care policies

28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 12/09/2024

1) The MD was made aware of R381's pain. Medication was administered as ordered, when available.
2) All residents experiencing pain have the potential to be affected. On November 1, 2024, the DON and/or designee observed all residents to ensure they were not experiencing acute pain. If necessary, the resident assessed, the MD/RP notified, and orders were carried out to manage the pain. No issues identified.
3) To prevent the potential for reoccurrence the DON and/or designee will educate licensed staff on pain management with emphasis on how to address pain when there is a pharmacy delay for medication delivery. Licensed staff will also be educated on how to escalate delivery issues to the DON, NHA, and Medical Director if there is a delay in medication approvals/delivery.
4) To monitor and maintain on-going compliance the DON/designee will review newly admitted residents 5 times a week for 3 months to ensure that their pain was addressed, should it be expressed. And, that pain medication was delivered from the pharmacy in a timely manner. If an issue is identified the resident will be assessed, MD/RP notified, pain management accommodated, and the responsible person reeducated. Findings will be reported to facility QAPI for continued review and recommendations.

483.10(h)(1)-(3)(i)(ii) REQUIREMENT Personal Privacy/Confidentiality of Records:

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.

�483.10(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(h)(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 observation, review of facility policy and interview with staff, it was determined that the facility did not ensure personal privacy and confidentiality related to signage for enhanced barrier precautions for 5 of 8 residents on transmission based precautions (Residents R56, R126, R117, R88 and R61).

Finding include:

Review of facility policy, title Resident Rights, revised September 3, 2020, revealed, "It is the facility's policy to comply with all Resident Rights, and to communicate these rights to residents and their designated representatives in a language they can understand."

Review of facility policy, Transmission Based Precautions and Isolation policy, last revised April 14, 2024 revealed: "Enhanced Barrier Precautions (EBP). EBP are intended to prevent transmission of multi-drug resistant organisms (MDROs) via contaminated hands and clothing of healthcare workers to highrisk residents. EBP are indicated for high contact care activities for residents with chronic wounds and indwelling devices (such as central lines, urinary catheters and trachs) and for all those colonized or infected with a MDRO currently targeted by the CDC."

Further review of the above policy revealed, "Signage indicating the appropriate type(s) of precautions and indicating that visitors should stop at Nurse's Station before entering, will be placed on the resident's door. Staff will educate visitors regarding donning appropriate Personal Protection Equipment while adhering to the resident's right for privacy protection."

Observation tour on October 31, 2024 at 11:00 a.m. revealed eight residents had transmission based precautions signage posted on their door. Five of eight transmission based precautions signs revealed personal and confidential medical information.

Transmission Based Precaution signage for Resident R56 revealed a staff member identified peg tube (feeding tube) and wound.

Transmission Based Precaution signage for Resident R126 revealed a staff member identified trach (tracheostomy), peg tube (feeding tube) and wound.

Transmission Based Precaution signage for Resident 117 revealed a staff member identified peg tube (feeding tube).

Transmission Based Precaution signage for Resident R88 revealed a staff member identified peg tube (feeding tube) and trach (tracheostomy).

Transmission Based Precaution signage for Resident R61 revealed a staff member identified foley (catheter)

28 Pa Code 211.12(c)(d)(1) Nursing services

Plan of Correction - To be completed: 12/09/2024

1) The Enhanced Barrier Precaution (EBP) signs for residents R56, R126, R117, R88, and R61 were removed from their doors upon discovery. The signs were immediately replaced.
2) All residents with EBP precautions have the potential to be affected. On November 1, 2024 the DON and/or designee audited all EBP signs to ensure that they did not display privacy information. Where necessary EBP signs were removed and replaced.
3) To prevent the potential for reoccurrence the DON and/or designee will educate licensed and certified staff on personal privacy/confidentiality records with emphasis on not displaying information where it can be observed publicly.
4) To monitor and maintain on-going compliance DON/designee will audit EBP signage weekly to ensure it does not display personal information. If an issue is identified the sign will be removed, replaced, and the responsible person reeducated. Findings will be reported to facility QAPI for continued review and recommendations.

483.60(c)(1)-(7) REQUIREMENT Menus Meet Resident Nds/Prep in Adv/Followed:

�483.60(c) Menus and nutritional adequacy.
Menus must-

�483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.;

�483.60(c)(2) Be prepared in advance;

�483.60(c)(3) Be followed;

�483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups;

�483.60(c)(5) Be updated periodically;

�483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and

�483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices.

Observations:

Based on observations, review of facility documentation, and resident interviews, it was determined that the facility failed to ensure menus were followed for 10 of 28 clinical records reviewed (Resident R32, R35, R43, R57, R99, R122 and R440R40, R59 and R109).

Finding include:

During lunchtime on October 29, 2024, at 1:08 p.m. Resident R109 complained that she did not order the chicken she was served and was given cranberry juice that she stated she was unable to drink. Review of Resident R109's lunch ticket indicated the resident requested roast beef, brown gravy, creamed spinach, and egg noodles. Also included on the lunch ticket was a request that indicated no cranberry juice.

Interview with Resident R59 on October 29, 2024, at 3:00 p.m. stated he always gets the wrong meal and never gets what he asks for.

Review of the grievance log revealed Resident R40 complained the kitchen serves the wrong food. Interview with Resident R40 on October 30, 2024, confirmed this still continues.

During resident council on October 30, 2024 at 1:00 p.m. with seven residents ( Resident R32, R35, R43, R57, R99, R122 and R440) voiced concerns that the served food did not match with the food ticket.

28 Pa. Code 201.18(b)(3) Management

Plan of Correction - To be completed: 12/09/2024

1) No adverse findings related to incorrect meal delivery for R32, R35, R57, R99, R122, R440, R40, R59, or R109.
2) All residents have the potential to be affected. On November 25, 2024 the Food Service Director (FSD) and/or designee observed meal trays on each unit (A, B, C, D) to determine if there were inaccuracies present. If an issue was identified the tray was replaced at the resident's preference.
3) To prevent the potential for reoccurrence the FSD educated all staff on the need to confirm tray accuracy against the resident's meal ticket before delivering the tray. Staff also educated on what to do if the meal is not correct.
4) To monitor and maintain ongoing compliance the FSD and/or designee will observe 10 random meal trays 5 days a week for 3 months to ensure that they are accurate against the resident's preferred menu choices. If an issue is observed the meal will be corrected and the responsible person immediately reeducated. Findings will be reported to facility QAPI for continued review and recommendations.

483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):

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(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in �483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in �483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in �483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

�483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in �483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under �483.15(c)(9).

Observations:

Based on review of clinical records, review of facility policies and procedures and interviews with staff, it was determined that the facility failed to promptly notify resident's physician of a fall with injury resulting in hospitalization during a leave of absence from the facility for one of six residents reviewed (Resident R6).

Findings include:

Review of facility policy titled "Resident Change in Condition Policy" dated June 27, 2024, revealed "The licensed nurse will recognize and intervene in the event of a change in resident condition. The Physician/Provider and the Family/Responsible Party will be notified as soon as the nurse has identified the change in condition and the resident is stable.

A "Significant Change" of Condition is a decline or improvement in the resident's status that:
1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical intervention[s]; and/or one that
2. Impacts more than one area of the resident's health status; and/or one that
3. Requires interdisciplinary review and/or revision to the care plan.
The Physician/Provider and Resident /Family/Responsible Party will be notified when there has been:
a. An accident or incident involving the resident;
b. A discovery of an injury
c. A reaction to medication or treatment;
d. A significant change in the resident's physical/emotional/mental condition;
e. A need to alter the resident's medical treatment, including a change in provider orders"
Review of Resident R6's nursing progress note dated August 11, 2024, revealed that resident went to leave of absence with family to church.

Review of Resident R6's nursing progress note dated August 11, 2024, revealed that resident returned to the nursing unit at 4:30 p.m., and, accompanied by brother. Resident's family was notified by the resident about hospitalization; and family picked up resident from the hospital by the car and transferred back to the facility. Resident noted with pain and discomfort. An abrasion was noted to right thumb, and pain noted to right side. As needed pain medication given.

Review of facility reported incident dated August 14, 2024, revealed that while on leave of absence with church members on August 11, 2024, approximately 1:30 p.m., Resident R6 sustained a witnessed fall at church landing on his right side and was taken to the hospital by a church member.

Review of Resident R6's entire clinical record revealed no documented evidence that the physician was notified promptly of Resident R6 fall while on leave of absence from the facility which resulted in injury and hospitalization.

Interview with the Regional Nurse, Employee E3 on November 1, 2024 at 12:00 p.m. confirmed that there was no evidence in the clinical record that the physician was notified promptly of Resident R6 fall while on leave of absence from the facility.

28 Pa. Code: 211.12(c)(d)(1)(2)(3)(5) Nursing services.

Plan of Correction - To be completed: 12/09/2024

1) MD was made aware of the incident involving R6.
2) All residents have the potential to be affected. On November 1, 2024 the Director of Nursing (DON) and/or designee reviewed all hospital transfers from date of survey exit to ensure the MD was made aware. If necessary, the physician was notified.
3) To prevent the potential for reoccurrence the DON and/or designee will educate licensed staff on notifications of changes with emphasis on hospital transfers.
4) To monitor and maintain on-going compliance DON and/or designee will review residents' charts 2 times a week for 3 months to ensure that MD notification is documented when a resident is discharged to the hospital. If an issue is identified the MD will be immediately notified, documentation updated, and the responsible person reeducated. Findings will be reported to facility QAPI for continued review and recommendations

483.20(g) REQUIREMENT Accuracy of Assessments:

�483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.

Observations:

Based on clinical record review and interviews with staff, it was determined that the facility failed to accurately complete a resident assessment related to discharge status for one of 27 residents reviewed (Resident R129).

Findings include:

Review of Resident R129's progress note revealed a nursing note dated July 31, 2024, which stated, resident discharged to home.

Review of Resident R129's discharge Minimum Data Set (MDS- assessment of resident care needs) dated July 31, 2024, revealed that the residents discharge status was coded, "Short term general hospital (acute hospital)."

Interview with the Registered Nurse Assessment Coordinator, conducted on November 1, 2024, at 11:30 a.m. confirmed that the MDS discharge status, dated July 31, 2024, for Resident R129 was coded inaccurately.

28 Pa. Code 201.14(a) Responsibility of licensee

2 Pa. Code 211.5(f) Medical records

Plan of Correction - To be completed: 12/09/2024

1) The discharge status for R129 was corrected on the minimum data set (MDS) at time of observation.
2) All discharged residents have the potential to be affected. On November 1, 2024 the MDS Coordinator and/or designee audited all discharges from time of survey exit to ensure that discharge was accurately documented. Where necessary the MDS was updated and resubmitted.
3) To prevent the potential for reoccurrence the DON will educate the MDS Coordinator on accurately coding discharge location on the MDS assessment.
4) To monitor and maintain on-going compliance the DON/designee will review all discharges that occurred in the last week to ensure accurate coding was completed on the MDS. If an issue is identified the MDS assessment will be updated, resubmitted, and the responsible person reeducated. Findings will be reported to facility QAPI for continued review and recommendations.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:

� 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Observations:

Based upon review of clinical records and interviews with family and review of facility documentation, it was determined that the facility did not ensure resident requiring continuous oxygen therapy received such services per the physician orders for one of 28 resident records reviewed (Resident R1).

Findings include:

Review of Resident R1's clinical record revealed that the resident was initially admitted to the facility in September 2022 for acute respiratory failure with hypoxia.
Review of the grievance log revealed Resident R1's family indicated during a visit they observed the resident without the oxygen mask, stating it was the third time this month.

Review of the Resident R1's October 2024 physician orders revealed an order for 2 liters of oxygen to be given continuously via nasal canula and to check the concentrator to endure functioning and appropriate setting.

Statement received by the nursing assistant indicated on May 14, 2024, she removed the oxygen mask while giving care and forgot to replace the mask.

28 Pa. Code 211.12(d)(1) Nursing services

28 Pa. Code 211.12(d)(5) Nursing services

Plan of Correction - To be completed: 12/09/2024

1) R1's oxygen was confirmed as being in place at time of observation.
2) All residents requiring continuous oxygen have the potential to be affected. On November 1, 2024, the DON and/or designee observed all residents with oxygen to ensure it was in place. If necessary, the oxygen was administered, the resident assessed, and the MD/RP notified. No issues identified.
3) To prevent the potential for reoccurrence the DON and/or designee will educate certified and licensed staff on oxygen therapy with emphasis on ensuring that continuous oxygen remains in place, as ordered.
4) To monitor and maintain on-going compliance the DON/designee will review 2 residents requiring continuous oxygen 5 times a week for 3 months to ensure that it is being used appropriately. If an issue is identified oxygen will be administered, the resident assessed, MD/RP notified, and the responsible person reeducated. Findings will be reported to facility QAPI for continued review and recommendations.

483.50(a)(1)(i) REQUIREMENT Laboratory Services:

�483.50(a) Laboratory Services.
�483.50(a)(1) The facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services.
(i) If the facility provides its own laboratory services, the services must meet the applicable requirements for laboratories specified in part 493 of this chapter.

Observations:
Based on clinical record review and staff interview, it was determined that the facility failed to ensure that laboratory studies were promptly obtained as ordered by the physician for one of 28 clinical records reviewed (Resident R107).

Findings include:

Review of Resident R107's physician progress note dated October 18, 2024, indicated that resident had complained of headache, dizziness, and lightheadedness. Resident's nurse practitioner was notified and ordered for lab work, CBC (complete blood count), CMP (complete metabolic panel), Urine culture and sensitivity, and electrocardiogram (EKG).

Further review of Resident R107's clinical records revealed the staff collected the urine sample on October 19, 2024, at night shift however it was not set to the lab in a timely manner.

Continued review of Resident R107's clinical records revealed the staff recollected the urine sample on October 21, 2024, and sent to the lab.

Review of clinical record for Resident R107 revealed no evidence that the staff obtained the result or inquired about the result of urine test result sent on October 21, 2024.

Interview with the Registered Nurse, Employee E5 on October 31, 2024, at 11:28 a.m. stated the urine container leaked on the way to the lab and it was discarded, lab tried to reach the facility but was unable to connect, no follow up was completed and no new urine sample was sent out.

28 Pa. Code 211.5(f) Clinical records

28 Pa. Code 211.10(c) Resident care policies

28 Pa. Code 211.12(d)(1)Nursing services

28 Pa. Code 211.12(d)(3) Nursing services

28 Pa. Code 211.12(d)(5) Nursing services

Plan of Correction - To be completed: 12/09/2024

1) R107's labs were obtained, and results provided to the physician.
2) All residents requiring labs have the potential to be affected. On November 1, 2024 the DON and/or designee audited all current orders to ensure that prescribed labs were completed. Where necessary the MD was notified of a delay, and new orders received.
3) To prevent the potential for reoccurrence the DON and/or designee will educate licensed staff on laboratory services with emphasis on ensuring that missed labs are rescheduled, and completed.
4) To monitor and maintain on-going compliance the DON/designee will review all new orders 5 times a week for 3 months to ensure labs are scheduled, completed, and reported to the MD as prescribed. If an issue is identified the MD/RP will be notified, and new orders received. Findings will be reported to facility QAPI for continued review and recommendations.

483.50(a)(2)(i)(ii) REQUIREMENT Lab Srvcs Physician Order/Notify of Results:

�483.50(a)(2) The facility must-
(i) Provide or obtain laboratory services only when ordered by a physician; physician assistant; nurse practitioner or clinical nurse specialist in accordance with State law, including scope of practice laws.
(ii) Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders.

Observations:

Based on the review of facility policies, clinical record review and staff interviews, it was determined that the facility failed to ensure that resident's physician was notified about abnormal laboratory test results for one of 28 residents reviewed (Resident R107).

Findings include:

Review of Resident R107's physician progress note dated October 18, 2024, indicated that resident had complained of headache, dizziness, and lightheadedness. Resident's nurse practitioner was notified and ordered for lab work, CBC (complete blood count), CMP (complete metabolic panel), Urine culture and sensitivity, and electrocardiogram (EKG).

Review of Resident R107's progress note dated October 19, 2024, indicated that the lab work was obtained, and the results were pending.

Review of resident's clinical record including paper record and electronic record available at the facility revealed no evidence that the lab results which was ordered on October 18, 2024, were available to review.

Interview with the Registered Nurse, Employee E5 on October 31, 2024, at 11:28 a.m. stated the lab work was completed for CBC and CMP, however it was not printed from lab electronic system and there was no evidence that the physician was notified.

Further review of Resident R107's laboratory studies which was printed by Employee E5 revealed the results of CBC and CMP completed on October 19, 2024, indicated that some of the results were flagged for out of range. Resident's blood Sodium level was 133 with a normal range of 136-144.

28 Pa. Code 211.5(f) Clinical records

28 Pa. Code 211.10(c) Resident care policies

28 Pa. Code 211.12(d)(1)Nursing services

28 Pa. Code 211.12(d)(3) Nursing services

28 Pa. Code 211.12(d)(5) Nursing services

Plan of Correction - To be completed: 12/09/2024

1) R107's labs were obtained, and results provided to the physician. The physician was notified late.
2) All residents requiring labs have the potential to be affected. On November 1, 2024 the DON and/or designee audited all current orders to ensure that prescribed labs were completed. Where necessary the MD was notified of a delay, and new orders received.
3) To prevent the potential for reoccurrence the DON and/or designee will educate licensed staff on laboratory services with emphasis on ensuring that missed labs are rescheduled, and completed.
4) To monitor and maintain on-going compliance the DON/designee will review all new orders 5 times a week for 3 months to ensure labs are scheduled, completed, and reported to the MD as prescribed. If an issue is identified the MD/RP will be notified, and new orders received. Findings will be reported to facility QAPI for continued review and recommendations.

483.90(g)(1)(2) REQUIREMENT Resident Call System:

�483.90(g) Resident Call System
The facility must be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from-

�483.90(g)(1) Each resident's bedside; and
�483.90(g)(2) Toilet and bathing facilities.

Observations:

Based on observations and staff interviews, it was determined that the facility failed to ensure that resident bathrooms were equipped with the appropriate call bell system for one out of 28 residents reviewed (Resident R21)

Findings include:

During an observation in Resident R21's on rooms on October 29, 2024, at 1:44 p.m. revealed that there was no wired call bell in residents' room, the wires were removed from the wall. Further observation revealed that there was a tap bell in the room across from resident's foot of the bed, which was out of reach for the resident who was laying in the bed. Resident R21 stated she uses the bell to call for staff and no one responds.

Further observation revealed that resident pressed the tap bell at 1.49 p.m. Resident stated she needed to be changed as she had an incontinence episode. Staff did not respond until 1:58 p.m. and the surveyor observed staff at the nurse's station. Employee E4 who was assigned staff for Resident R21 stated she saw the bell sitting across from the resident when she was in her room before, but she thought the resident have a corded call bell.

Observation in Resident R21's on rooms on October 30, 2024, at 11:14 a.m. revealed that the resident pressed the tap bell numerous times. Resident was lying on the bed and stated she wanted to get ready to go lunch.

There was no response from staff until 11:27 a.m., it was revealed that the tap bell was not audible at the nurse's station, where there was music playing in the next room.

Further observation on October 30, 2024, at 11:28 a.m. revealed that Registered Nurse, Employee E5 was passing medication in the hallway two rooms away from the resident. Employee E5 stated she did not hear the tap bell.

During an interview with the Nursing Home Administrator and the Regional Nurse on November 1, 2024, at 12:00 p.m. stated the call system provided for Resident R21 was not adequate.

28 Pa. Code 205.67(j) Electric requirements for existing construction

Plan of Correction - To be completed: 12/09/2024

1) R21 was moved closer to the nursing station to ensure tap bell could be heard when sounded. The resident's call bell cord was removed due to suicidal ideation. The call bell system is operable and not broken.
2) All residents requiring tap bells have the potential to be affected. On November 1, 2024, the DON and/or designee observed all residents with tap bells to ensure that calls could be heard from the hallway and the nursing station. Where necessary accommodations were made to ensure that call response was maintained.
3) To prevent the potential for reoccurrence the DON and/or designee will educate all staff on call bell response with emphasis on ensuring that tap bells can be heard from the hallway and the nursing station; and the need to report diminished sound if identified.
4) To monitor and maintain on-going compliance the DON/designee will observe all residents with tap bells to ensure their bell can be heard when sounded 1 time weekly for 3 months. If an issue is identified accommodations will be made to ensure call response is corrected, and the responsible person reeducated. Findings will be reported to facility QAPI for continued review and recommendations.

483.95(g)(1)-(4) REQUIREMENT Required In-Service Training for Nurse Aides:

�483.95(g) Required in-service training for nurse aides.
In-service training must-

�483.95(g)(1) Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year.

�483.95(g)(2) Include dementia management training and resident abuse prevention training.

�483.95(g)(3) Address areas of weakness as determined in nurse aides' performance reviews and facility assessment at � 483.71 and may address the special needs of residents as determined by the facility staff.

�483.95(g)(4) For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired.

Observations:

Based on review of personnel files and interviews with staff, it was determined that the facility failed to ensure that nurse aides received at least 12 hours of continuing education per year as required for three of five nurse aide personnel files reviewed (Employees E6).

Findings include:

A copy of five nurse aide employee educational record was requested to the facility administrator on November 1, 2024, at 9:30 a.m.

Review of personnel files for Employees E6, Certified Nursing Assistant, revealed that there was no evidence that the employees completed at least 12 hours of continuing education per year as required.

Interview on November 1, 2024, at 1:00 p.m. the Nursing Home Administrator revealed that there were no 12-hour educational records for Employees E6 at the time of the survey.

28 Pa Code 201.19(7) Personnel policies and procedures

28 Pa Code 201.20(d) Staff development

Plan of Correction - To be completed: 12/09/2024

1) Completion requirements for 12 Hour Certified Nursing Assistant (CNA) Mandatory Education was initiated with E6.
2) All CNAs having worked at Bryn Mawr for greater than 1 year have the potential to be affected. On November 25, 2024, the Nursing Home Administrator (NHA) and/or designee audited to ensure that those aides had completed their mandatory training. Where necessary mandatory education was initiated and completed.
3) To prevent the potential for reoccurrence the NHA and/or designee educated all certified staff on the importance of completing their 12 Hour Mandatory Education along with the process for doing so.
4) To monitor and maintain on-going compliance the NHA and/or designee will monitor Mandatory Education requirement completion 2 times a month for 3 months. If an issue is observed the responsible person will be directed to complete their education. They will also be re-educated on the importance of this process. Findings will be reported to facility QAPI for continued review and recommendations.

� 201.14(c) LICENSURE Responsibility of licensee.:

(c) The licensee through the administrator shall report as soon as possible, or, at the latest, within 24 hours to the appropriate Division of Nursing Care Facilities field office serious incidents involving residents as set forth in � 51.3 (relating to notification). For purposes of this subpart, references to patients in � 51.3 include references to residents.

Observations:

Based on review of facility documentation, review of clinical records, and resident interviews, it was determined that the facility failed to submit complete and accurate information to the State Survey Agency regarding a resident fall and subsequent transfer to the hospital while on leave of absence (LOA) for one of 5 residents reviewed for facility reported incidents (Resident R6).

Findings Include:

Review of facility reported incident dated August 14, 2024, revealed that "While on LOA with church members on 8/11/2024 approximately 1:30 p.m. Resident R6 who has a BIMS (Brief Interview for Mental Status) score of 12 sustained a witnessed fall at church landing on his right side and was taken to the (Name of the Hospital) by a church member. Resident retuned to facility in stable condition on 8/11/2024 at 4:30 p.m. and did not report the incident to nursing until 8/14/2024 when he then produced hospital paperwork to NP (Nurse Practitioner).

Review of Resident R6's nursing progress note dated August 11, 2024, revealed that resident returned to the nursing unit at 4:30 p.m., and, accompanied by brother. Resident's family was notified by the resident about hospitalization; and family picked up resident from the hospital by the car and transferred back to the facility. Resident noted with pain and discomfort. An abrasion was noted to right thumb, and pain noted to right side. As needed pain medication given.

Further review of the progress note revealed that the facility was aware of the hospitalization and injury to the resident while on leave of absence.

Review of Resident R6's nursing progress note dated August 12, 2024, revealed that the resident noted with pain from the fall while away from the facility. Resident was given pain medication. Staff was notified by the church member that resident fell at church.

Interview with the Licensed Practical Nurse, Employee E7 on November 1, 2024, at 11:00 a.m. stated she provided care to the resident on August 12, 2024, and the resident was on the report for fall injury and was monitored for pain from August 11, 2024.

Interview with the Regional Nurse, Employee E3 on November 1, 2024 at 12:00 p.m. confirmed that there was evidence in the clinical record that the facility was aware of the resident's fall while on LOA. Employee E3 also confirmed that the facility information submitted to the Department of Health electronic submission was inaccurate and the facility did not report the incident in a timely manner.

28 Pa Code: 201.14 (a) Responsibility of licensee.

28 Pa Code: 201.18 (b)(1) Management.

Plan of Correction - To be completed: 12/09/2024

1) Inaccurately reported information for R6's hospitalization was reviewed and discussed with the state surveyor at time of discovery.
2) All residents have the potential to be affected. On November 25, 2024, the DON and/or designee reviewed all reportable event summaries from date of survey exit against the clinical record to ensure accuracy. If necessary, the Department of Health was called and notified of the needed change.
3) To prevent the potential for reoccurrence the Regional Director of Clinical Services (RDCS) re-educated the NHA and DON on the process for reporting significant events to the Department of Health with emphasis on factual accuracy.
4) To monitor and maintain on-going compliance the NHA will observe state reported significant event summaries against the investigation documents 1 time a week for 3 months to verify accuracy. If an issue is observed the NHA will correct the summary, inform the Department of Health, and immediately re-educated the responsible party. Findings will be reported to facility QAPI for continued review and recommendations.

� 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Plan of Correction - To be completed: 12/09/2024

1) No adverse occurrences identified related to minimum staffing ratios not being met.
2) Staffing ratios from date of survey exit to present November 25, 2024, were reviewed to ensure that staffing ratios were met. Where necessary, missed ratios were discussed with the Staffing Coordinator, and the need to appropriately meet those ratios reinforced.
3) To prevent the potential for recurrence the NHA re-educated the Staffing Coordinator and the Director of Nursing on state mandated staffing ratios and the need to meet them.
4) To monitor and maintain on-going compliance the NHA and/or designee will hold a staffing meeting 5 times a week for 3 months to ensure that ratios are met. If a deficit is observed the facility will work to proactively fill open positions before the shift starts. Findings will be reported to facility QAPI for continued review and recommendations.

� 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:

Based on review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure the total of nursing care hours provided in each 24-hour period was a minimum of 3.2 hours per patient day (PPD), effective July 1, 2024, on two of the 21 days reviewed. (September 14, 15, 2024)

Findings include:
Review of nursing staff care hours provided by the facility revealed that the facility failed to meet the minimum hours per patient day on the following dates:

September 14, 2024, with 3.07 hours per resident per day
September 15, 2024, with 3.04 hours per resident per day

The facility failed to meet the required nursing staffing PPD.

Interview with the Nursing Home Administrator on November 1, 2024, at 2:00 PM confirmed the above noted findings related to the nursing PPD.

Plan of Correction - To be completed: 12/09/2024

1) No adverse occurrences identified related to minimum PPD not being met.
2) PPD from date of survey exit to present November 25, 2024, were reviewed to ensure that staffing PPDs were met. Where necessary, missed PPD was discussed with the Staffing Coordinator, and the need to appropriately meet those ratios reinforced.
3) To prevent the potential for recurrence the NHA re-educated the Staffing Coordinator and the Director of Nursing on state mandated PPDs and the need to meet them.
4) To monitor and maintain on-going compliance the NHA and/or designee will hold a staffing meeting 5 times a week for 3 months to ensure that minimum PPDs are met. If a deficit is observed the facility will work to proactively fill open positions before the shift starts. Findings will be reported to facility QAPI for continued review and recommendations.

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