|§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 maintain clinical records that were complete and accurately documented for one of two residents reviewed (Resident 1).
The facility's policy regarding medication administration, dated June 15, 2018, revealed that after staff administered medications they were to document the administration in the Medication Administration Record (MAR) or Treatment Administration Record (TAR).
A nursing note for Resident 1, dated February 15, 2019, at 11:40 a.m. revealed that Licensed Practical Nurse 1 called and stated that Resident 1 was "crashing." An insulin order was misinterpreted and 100 units of Humalog (fast-acting insulin) were administered to Resident 1. Upon entering the resident's room, he was hard to arouse, and Licensed Practical Nurse 1 stated that one tube of Glucagon (a gel administered orally to raise blood sugar) was given 10 minutes prior. The resident's blood sugar was rechecked, and the reading was 38 mg/dL (normal blood sugar for a person with diabetes is 70 to 100 milligrams/deciliter (mg/dL) before meals). The resident was cold and clammy and would respond by opening his eyes when his name was called, and chest rub was applied. Another tube of Glucagon was given, and the resident's blood sugar was checked 10 minutes later and was 47 mg/dL.
A nursing note for Resident 1, dated February 15, 2019, at 1:00 p.m. revealed that Licensed Practical Nurse 1 misinterpreted the Humalog order and administered 100 units of insulin to Resident 1 at 7:52 a.m. Licensed Practical Nurse 1 returned to the resident's room at 11:35 a.m. and the resident was found unresponsive. The resident's blood sugar reading was 10 mg/dL. At this time the resident was assessed and was lethargic, hard to arouse, and cold and clammy. The physician was updated, and orders were received to administer 1 mg of Glucagon intramuscularly (IM - injected into the muscle) every 15 minutes for a blood sugar less than 60 mg/dL, if the resident had symptoms and was unable to take anything by mouth. At 11:43 a.m. the resident received IM Glucagon for a blood sugar result of 38 mg/dL and at 12:02 p.m. for a blood sugar result of 24 mg/dL. The physician was notified, and new orders were received for 1 ml of Dextrose (medication used to raise blood sugar levels) IM to be given, and the Dextrose was administered at 12:20 p.m. with blood sugar response of 78 mg/dL.
Resident 1's MAR for February 2019 revealed that there was no evidence that staff documented the administration of the Glucagon gel, the Glucagon injection, or the Dextrose injection on the MAR on February 15, 2019.
Interview with the Director of Nursing on February 22, 2019, at 3:14 p.m. confirmed that Resident 1's MAR did not include the administration of Glucagon gel, Glucagon injection, or Dextrose injection.
28 Pa. Code 211.5(f) Clinical records.
| ||Plan of Correction - To be completed: 04/05/2019|
Hypoglycemic orders were entered into resident R1's orders when he returned from his hospitalization.
The Director of Nursing completed audit to ensure residents ordered insulin also had hypoglycemic protocol orders in place. Physician was contacted for residents that did not have the hypoglycemic protocol orders and new orders were obtained.
Staff Educator completed in-service with licensed professional staff. Hypoglycemic protocol was educated on and it was emphasized that residents who are ordered insulin must also have hypoglycemic orders initiated.
Licensed staff were also educated on facility's Electronic Signature Policy in which users are required to review their entries for completeness and accuracy prior to electronically signing the progress notes, assessments, electronic medication administration record and electronic treatment administration record.
Director of Nursing or designee will audit monthly for three months insulin orders to ensure accuracy and completeness.
Results of the audits will be reported and trended to the facility's Quality Assurance Steering Committee, which is the Centers for Medicare & Medicaid Services (CMS) recommended structure for Quality Assurance Performance Improvement Plan (QAPI). The Quality Assurance Steering Committee will determine the frequency of the audits after the initial three months are completed and results are reviewed according to the trends recommendations and guidance via facility Quality Assurance Performance Improvement Plan (QAPI).