|§483.20(f)(5) Resident-identifiable information.|
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.
§483.70(i) Medical records.
§483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized
§483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.
§483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.
§483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.
§483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for one of 42 residents reviewed (Resident 30).
A care plan for Resident 30, dated December 13, 2017, revealed that the resident had diagnoses that included diabetes (a disease that interferes with the body's ability to control blood sugar levels). A nursing note, dated April 11, 2019, revealed that Resident 30 stated he was not feeling well, wanted his sugar checked, and it was 41 milligrams per deciliter (mg/dL) (below normal). A nursing note, dated April 11, 2019, authored by Registered Nurse 5, revealed that she administered oral glucose into the resident's jejunostomy tube (a tube surgically inserted into the small intestine) and gave him juice to drink. There was no documented evidence of a physician's order for oral glucose to be administered via the jejunostomy tube.
Interview with the Nursing Home Administrator on April 18, 2019, at 2:42 p.m. revealed that the facility did not have a policy in place to address hypoglycemia (low blood sugar) and that the nurses would treat the resident according to the physician's orders.
An interview with Registered Nurse 5 on April 18, 2019, at 3:09 p.m. revealed that she called the doctor after she checked Resident 30's blood sugar and she forgot to write the physician's order for the oral glucose that she administered to Resident 30 via the jejunostomy tube.
An interview with Physician 6 on April 18, 2019, at 4:24 p.m. revealed that he did not recall if he gave the specific order to Registered Nurse 5 to administer oral glucose via the jejunostomy tube; however, he has ordered that oral glucose be administered into a feeding tube in the past.
28 Pa. Code 211.5(f) Clinical records.
| ||Plan of Correction - To be completed: 06/11/2019|
1. Order documented for Resident 30 to receive instant glucose gel via jejunostomy tube.
2. Nurses obtaining verbal orders will be educated by Director of Nursing or designee, to complete documentation efficiently.
3. Education to licensed nurses by Director of nursing or designee, on procedures for documenting verbal orders completely and accurately in the clinical record.Education will be provided to licensed nurses to include proper route of administration. Interdisciplinary team reviews orders daily to ensure orders are complete.
4. Audits will be completed by Director of Nursing or designee on random nurse notes to verify that orders are in clinical record and documented accurately. 5 days a week for 1 week, weekly for 2 weeks and monthly for 2 months. Results of audits will be provided to the Quality Assurance Performance Improvement committee for further review and recommendations.