|§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 clinical records and select facility reports and staff interview, it was determined that the facility failed to maintain complete and accurate records for one of 15 residents sampled (Resident CR1).
A review of the clinical record of Resident CR1 revealed admision to the facility on November 13, 2018, with diagnoses that included anxiety, and hypertension. The resident was hospitalized on January 4, 2019, and discharged from the facility that same date.
Review of Resident CR1's clinical record revealed physician progress notes for November 2018. Interview with the Director of Nursing on February 16, 2019, revealed that the resident was seen by the CRNP (Certified Registered Nurse Practitioner) in November 2018, December 2018, and January 2019, but there was no documentation in Resident CR1's clinical record to support these visits. Following surveyor inquiry, the facility printed out notes from an electronic system (EPIC) used by the CRNP (not a part of the resident's clinical record) to provide evidence that Resident CR1 was seen every month for the first 90 days. There was no documentated evidence of these physician/physician extender visits in Resident CR1's clinical record.
A review of nurses notes in Resident CR1's clinical record revealed that that the resident had a fall at 12:15 a.m. on January 3, 2019. The nurses note indicated that there were no obvious signs of injury. From the time of the fall at 12:15 a.m. on January 3, 2019, until a nurses note on January 4, 2019, at 1:50 p.m. there was no indication that the resident displayed signs of injury or pain. However, a nurses note dated January 4, 2019, at 1:50 p.m. indicated a drug interaction between Tramadol and Sertraline. The resident was receiving Sertraline prior to the fall, but not Tramadol. There was no documentation of the resident's pain or that the physician or CRNP had been notified and nursing had received an order for Tramadol.
Nurses note on January 4, 2019, at 1:51 p.m. indicated that the CRNP was made aware of the drug interaction. A nurses note dated January 4, 2019, at 1:54 p.m. noted that the CRNP ordered Tramadol for pain and that the resident's responsible party was aware.
A nurses note dated January 4, 2019 at 5:54 p.m. indicated that the x-ray results revealed that the resident had a left hip femur fracture.
There was no indication in Resident CR1's clinical record that the resident had complained of pain, signs or symptoms of a fractured hip or that an x-ray had been ordered.
Interview with the Director of Nursing on February 16, 2019 at 2:00 p.m. confirmed that the resident's clinical record was incomplete and lacked necessary documentation of physician visits, nursing assessment and monitoring of the resident after a fall, signs and symptoms of injury and the care and services provided to the resident in response to these clinical findings and identified injury.
28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.
Previously cited: 7/20/18
28 Pa. Code 211.5 (f) Clinical records.
Previously cited: 7/20/18
| ||Plan of Correction - To be completed: 04/02/2019|
Cannot correct clinical record for CR1 record is closed, resident had been discharged from the facility.
Current resident clinical records will be reviewed and updated with current CRNP documentation of visits. With the occurrence of an Incident/Accident nursing documentation will be reviewed to ensure a comprehensive assessment and corresponding documentation is present in resident's clinical record.
Medical Records staff will be educated on the importance and responsibility of ensuring Physician/CRNP progress notes will be placed in the resident's chart or downloaded into the clinical record. Licensed nursing staff will be educated on their responsibility for proper documentation that shows consistency and follow through to clearly explain the condition and outcome of resident's condition in their documentation. Re-education will be provided for failure of adequate documentation.
DON/designee will randomly audit nursing documentation to identify and ensure Licensed staff are completing documentation and outcomes in a clear consistent manner. The results of the audits will be reviewed with the QAPI committee to determine if additional audits or education is needed.