Pennsylvania Department of Health
Patient Care Inspection Results

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Inspection Results For:

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BRADFORD REGIONAL MEDICAL CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

This report is the result of an unannounced onsite complaint investigation (CHL23C191A) completed on May 2, 2023, with review of additional information concluding on May 23, 2023, at Bradford Regional Medical Center. It was determined that 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:

103.38 LICENSURE EDUCATION PROGRAMS:State only Deficiency.
103.38 Education programs

Orientation and inservice training programs should be provided in order that hospital personnel may maintain their skills and learn new developments in health care.

Based on review facility documentation, personnel files (PF), and employee interview (EMP), it was determined the facility failed to provide in-service training programs on an annual basis for four of ten employee personnel files reviewed (PF26, PF27, PF28 and PF29).

Findings include:

Review on May 4, 2023, at approximately 9:10 AM of the "Bradford Regional Medical Center 2022 Mandatory Education - Section B: Patient Rights" revealed required "EMTALA - Emergency Medical Treatment and Leave Act" education was part of mandatory training to be included within the document.

EMP6 confirmed that EMTALA education was required to be completed by January 31, 2023.

Review on May 5, 2023, between approximately 10:00 AM and 11:30 AM of PF26, PF27, PF28, and PF29, revealed no documentation the staff completed the required EMTALA education prior to January 31, 2023. EMP10 confirmed the PF26-PF29 worked within the facility after January 31, 2023.

 Plan of Correction - To be completed: 07/01/2023

Following PA-DOH onsite visit on 5/2/2023 all ED nursing staff were reeducated on EMTALA including a power point presentation and a post test. This was done to meet the requirement for annual EMTALA education for the year 2023. Annual mandatory education is being monitored by the Nurses Services Manager quarterly to ensure completion. Compliance will be monitored and reported Quarterly at Patient Safety Committee meeting.
117.41 (a) LICENSURE EMERGENCY PATIENT CARE:State only Deficiency.
117.41 Emergency patient care
(a) Emergency patient care shall be
guided by written policies and
procedures which delineate the proper
administrative and medical procedures
and methods to be followed in
providing emergency care. These
policies and procedures shall be clear
and explicit; approved by the medical
staff and hospital governing body;
reviewed annually, revised as
necessary; and dated to indicate the
date of the latest review or revision,
or both.

Based on review of facility documentation and employee interview (EMP), it was determined the facility failed to ensure medical command communication was documented on the medical command form and maintained for five years for one of two Emergency Medical Services (EMS) diversions.

Findings include:

Review on May 2, 2023, at approximately 1:15 PM of Policy # 6780.324 "Medical Command," revised August 2017, revealed "... 4) Procedure: ... f) Medical command communication must be documented on the medical command form. ... g) Medical command form (written document) must be maintained for a minimum of five years. ..."

Employee interview (EMP) conducted on May 3, 2023, and May 4, 2023, with EMP1, EMP2, EMP3, and EMP4 confirmed that Emergency Medical Services (EMS) was diverted away from Bradford Regional Medical Center on March 29, 2023.

Review on May 2, 2023, at approximately 1:55 PM of the "Medical Command Communication Record" log revealed no documentation of an EMS Diversion on March 29, 2023. EMP2 confirmed that communication was required to be documented within the Medical Command Communication book. EMP2 was unable to provide an explanation why there was no documentation in the Medical Command Communication book.

On May 4, 2023, EMP7 confirmed the identified diversion on March 29, 2023, was not found within the Medical Command Communication Form Log.

This finding was confirmed by EMP8 on May 2, 2023.

 Plan of Correction - To be completed: 05/01/2024

A policy read and sign will be completed by all ED providers on policy 6780.324 Medical Command to ensure all providers are educated on the need to complete the Medical Command Form for records for each Medical Command call received. Completion of this form will be monitored by the Nurses Services Manager on a monthly basis to ensure compliance until 100% compliance is reached for 3 consecutive months. Audits will be sent to Quality monthly to be reported at Patient Safety Committee.

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