INITIAL COMMENTS
|
This report is a result of an on-site complaint investigation conducted on August 11, 2013 by staff from the Program Licensure Division. Based on the findings of the complaint investigation, the allegations against BGI of Brandywine, Inc., were partially substantiated. 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 complaint investigation:
|
Plan of Correction
|
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
|
Observations
Based upon observation and an interview with the facility director during an on-site complaint investigation, the facility failed to secure patient records in a locked storage container.
The findings include:
The Licensing Specialist Supervisors requested several patient records during a complaint investigation conducted on 8/11/13. The facility was unable to locate patient record # 144266 at the time of the inspection.
The facility director confirmed that they were unable to locate the patient record during the time of the inspection.
|
Plan of Correction
Director of Nursing was re-educated that all charts, regardles of circumstances, are to be secured behind two locks when the chart is not in use.
Additionally, maintenance will provide a master key to be kept in the nursing area, for the medical records chart room to assure accessibilty to the double locked records area for discharged patient charts if "after hours."
Executive Director will assure proper compliance by weekly spot checks in the Director of Nursing's office. |
715.23(b)(6) LICENSURE Patient records
(b) Each patient file shall include the following information:
(6) Results of laboratory tests or other special examinations given by the narcotic treatment program.
|
Observations
Based upon a review of the client record and information provided by the facility director, the facility failed to include documentation of serology in the patient record.
The findings include:
The patient was admitted for treatment on 6/29/13 and the treatment plan developed on 6/129/13 stipulated that a Mantoux test was to be completed and read within 72 hours. This test was to be completed no later than 7/2/13. There was no documentation of the test being completed as of the date of the patient's discharge on 7/5/13. The facility director confirmed that the test had not been completed nor was the reason appropriately documented.
The facility director confirmed that the patient was to have blood work completed. The facility director indicated that since the patient arrived on a Saturday (6/29/13) and the phlebotomist is scheduled on site each Monday and Tuesday, that the blood work should have been completed on Monday 7/1/13 unless the patient refused. The facility director acknowledged that there was no documentation indicating that the patient refused the tests.
|
Plan of Correction
Director of Nursing and Assistant Director of Nursing created checklist of all pertinent charting items that are to be checked on a daily basis by the Charge Nurse or designee.
This checklist includes accurate mantoux test readings and bloodwork completion.
Compliance with this standard will be assured with 100% chart checks that happen on the 3rd shift daily by the charge nurse or designee. The Director of Nursing and/or Assistant Director of Nursing will assure these are completed. |