INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the June 21, 2011 through June 24, 2011 licensure renewal inspection. The follow-up inspection was conducted on December 29, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, BGI of Brandywine, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection.
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Plan of Correction
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709.32(c)(2) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(2) Drug storage areas.
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Observations
Based on review of the policy and procedure manual and observation, the facility failed to have topical medication stored separately from oral medication.
The findings include:
The policy and procedure manual was reviewed on June 22, 2011. According to the policy and procedure manual the medication storage policy stated, "External use drugs in whatever form shall be stored separately from drugs for internal use and in a section marked externals." The nurses station was inspected on December 29, 2011. The medication carts were inspected and it was observed that the topical medications were being stored with the oral medications. The topical medications were stored in ziplock bags with the oral medications.
The Assistant Director of Nursing confirmed this finding.
This is a repeat citation from the June 21, 2011 through June 24, 2011 licensure renewal inspection.
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Plan of Correction
All drawers are labeled and medications separated accordingly. Staff re-educated on said standard. DON and/or ADON will do random spot checks at least daily. This item has been added to the medication nurse's shift check as well to to assure ongoing compliance. |
709.63(a)(7) LICENSURE Discharge summary
709.63. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(7) Discharge summary.
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Observations
Based on the review of the policy and procedure manual and client records, the facility failed to document discharge summaries seven days of discharge in five of five required records.
The findings include:
The policy and procedure manual was reviewed on June 22, 2011. According to the policy and procedure manual discharge summaries are to be completed within seven days of discharge. Nine patient records were reviewed on December 29, 2011. Five of those records were of discharged clients and required a discharge summary. Client records #1, 2, 3, 4, and 11 failed to have a completed discharge summary within the required seven days of discharge. The staff that completed the form failed to date their signature. There was no way to determine if the discharge summary was completed in the required time frame.
An interview with the assistant director of nursing confirmed this finding.
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Plan of Correction
All nursing staff will re-educated regarding this standard by 1/27/2012. The discharging nurse will be responsible for completing required discharge summary. Medical Records will be responsible for informing the DON and/or ADON of any deficiencies related to this standard so that they may hold appropriate staff accountable. |