|§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, census information and resident's clinical records, as well as observations and staff interviews, it was determined that the facilty failed to ensure that clinical records were complete and accurately documented for four of eight residents reviewed (Residents 1, 5, 6, 8).
The facility's policy regarding room to room transfers, dated February 20, 2019, indicated that documentation of the room transfer would be recorded in the resident's medical record.
A facility census report revealed that Resident 1 was moved into a room with Resident 8 on February 22, 2019. There was no documented evidence in Resident 1's clinical record regarding when he was moved into the room with Resident 8. There was also no documented evidence in Resident 8's clinical record that he received written notice that he was getting a new roommate.
Interview with the Social Worker on April 10 2019, at 5:00 p.m. confirmed that there was no documentation in Residents 1 and 8's clincal records regarding the room change.
An admission assessment for Resident 5, dated March 29, 2019, revealed that the resident had an open ulcer to the left lower leg, and physician's orders dated March 29, 2019, revealed that staff were to wash the ulcer on the resident's left lower leg with normal saline solution and then apply Santyl ointment (removes dead tissue) daily. However, a wound note written by Licensed Practical Nurse 2, dated April 1, 2019, indicated that Resident 5 had an open area on the right lower leg versus the left lower leg.
An interview with the Director of Nursing on April 10, 2019, at 12:01 p.m. confirmed that Resident 5 had an open area on the left lower leg, not the right lower leg.
Physician's orders for Resident 6, dated March 7, 2019, included an order for the resident to have an indwelling urinary catheter (a tube placed and held in the bladder to drain urine) and to monitor the resident's urinary output every shift. The resident's Treatment Administration Record (TAR) for March 2019 revealed that the resident's urinary output was not documented during the day shift on March 13, 14, 15, 19, 20; during the evening shift on March 19, 20 and 21; and during the night shift on March 13, 14, 15, 17, 18, 19, 20 and 21, 2019.
An interview with the Director of Nursing on April 10, 2019, at 12:03 p.m. confirmed that Resident 6's urinary output was not charted on the above shifts.
42 CFR 483.20(f)(5), 483.70(i)(1)-(5) Resident Records - Identifiable Information.
Previously cited 11/7/18.
28 Pa. Code 211.5(f) Clinical records.
Previously cited 11/7/18.
| ||Plan of Correction - To be completed: 05/15/2019|
1) Corrective Action for those residents found to be affected by the alleged deficient practice.
Residents #1, #5, #6, and #8 have since been discharged from the facility.
2) Corrective Actions taken for residents with potential to be affected by alleged deficient practice.
Residents admitted into the facility have the potential to be affected. Audit completed on recent resident room changes to ensure proper notifications for resident(s) that are moving or the resident that is getting the new roommate and documented as appropriate. Audit completed on residents with pressure ulcers to ensure the skin progress notes match with the physician orders on the treatment sheets and addressed as appropriate. Audit completed on residents with foley catheters to ensure urinary output is placed in the electronic treatment record each shift to be recorded. Clear delineation of who is responsible for room change notifications were discussed with the team by the administrator. The treatment nurse is responsible ensuring accurate documentation exist between the physician and the nurse documentation on a daily basis. There was no dedicated space for foley catheter output on the paper medication administration record with the electronic medication record the output will be apart of the batch order set.
3) Systemic Changes put into place to ensure the alleged deficient practice does not recur.
Education to social services departments on ensuring residents and resident's new roommates receive proper documented notification of changes. Education to licensed nurses on the ensuring that the electronic treatment record accurately reflects the correct skin site on physician orders. Education to licensed nurses on ensuring the urinary output is inputted and documented on each shift in the electronic treatment administration record.
4) Monitoring of corrective action to ensure the alleged deficient practice does not recur.
Director of Social Services will audit documentation of room changes to all necessary parties weekly x 4 weeks and monthly x 2 months. Director of nurses will audit wound notes for accuracy of skin treatment sites and urinary output weekly x 4 weeks and then monthly x2.
Plan of correction information and audits will be reviewed in the quality assurance and performance improvement process for tracking/trending and any necessary additional interventions.
Date of compliance-5/15/19