|§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 a review of clinical records and resident incident reports and staff interview, it was determined that the facility failed to maintain complete and accurate records for one of 15 resident's sampled (Resident 71).
A review of Resident 71's clinical record revealed that the resident was admitted to the facility on January 25, 2015, and had current diagnoses to include spinal stenosis (condition where spinal column narrows and compresses the spinal cord), migraines (A severe throbbing pain, generally experienced on one side of the head), and a C1 (neck) vertebra fracture.
Nursing progress notes dated December 23, 2018, at 11:25 p.m. revealed that a registered nurse received notice from the hospital that Resident 71 was being transferred to a different hospital for a C1 fracture. The resident returned to the facility on December 26, 2018.
However, nursing progress notes dated December 27, 2018, at 1:57 p.m. revealed that the resident was a re-admit with a diagnosis of a fractured C4, neck collar in place, and her vital signs are stable.
Nursing progress notes dated December 27, 2018, at 6:27 p.m. revealed that the resident was a re-admit alert and verbally responsive, with a diagnosis of a fractured C2, neck brace left in place.
Nursing progress notes dated December 28, 2018, at 3:04 a.m. revealed that the resident is a re-admit with a diagnosis of a C2 fracture. Cervical collar in place. Nursing progress notes dated January 2, 2019 at 11:22 p.m., indicated that the resident is a re-admit with a fractured C2.
Nursing progress notes dated December 28, 2018, at 11:22 p.m., December 29, 2018, at 8:30 a.m., December 30, 2018, at 10:10 a.m., December 31, 2018, at 1:13 p.m. December 31, 2018, at 8:15 p.m. January 1, 2019, at 8:00 a.m. January 1, 2019 at 12:58 p.m. January 1, 2019 at 10:46 p.m., January 2, 2019 at 3:59 a.m., indicated the resident was readmitted with a fractured C4
A review of the facility investigation and facility information dated December 23, 2018, both indicated that the resident incurred a C1 fracture.
Interview with the Director of Nursing on February 22, 2019 at 11:30 a.m. confirmed that the resident had sustained a C1 fracture and that nursing staff had erroneously documented both C2 and C4 fractures in their progress notes.
Progress notes dated January 18, 2019, at 6:25 a.m. indicated that the IDCP (interdisciplinary care plan) committee met to discuss the resident's incident. The investigation revealed that the resident had a history of falls and has a bed pad alarm. Resident 71 has a left bedside floor mat, chair pad alarm, and clip tab to chair. The note also addressed a fall the resident had incurred from a Broda chair and no injuries indicated at the time of the fall; but 6 to 7 hours later the resident complained of neck pain and was sent to the hospital for evaluation.
Review of a facility investigation and facility information dated January 18, 2019, both indicated that resident had a fall, but during the late morning early afternoon, occurring after the entry noted January 18, 2019, at 6:25 AM.
Interview with the Director of Nursing on February 22, 2019, at 11:30 a.m. revealed that the progress note on January 18, 2019 at 6:25 a.m. was referring to the incident that occurred on December 23, 2018. However, the entry dated January 18, 2019, failed to identify the date the incident being discussed had occurred, December 23, 2018.
Progress notes dated January 18, 2019, at 8:07 a.m. revealed that the resident was awake most of the night, screaming, yelling. The resident's neck brace was in place. Nursing noted that the resident was climbing out of bed and climbing out of her chair. Nursing administered Tylenol to the resident, which was noted to be ineffective. The resident was repositioned several times, but still uncomfortable. The physician was made aware and new order for Tramadol (a narcotic pain medication) was obtained. However, the Tramadol was discontinued as the result of the resident's allergy to Morphine.
Progress notes dated January 18, 2019, at 12:05 p.m. indicated that the resident was in bed, with the neck brace in place, yelling and crying and unable to explain why. Nursing shift report was received from previous shift of duty indicating that the resident had not slept last night. The physician was made aware and a new order to transfer the to the hospital for further evaluation was given. The resident left the facility via stretcher with two ambulance attendants to the hospital.
Nursing progress notes dated January 18, 2019 at 12:55 p.m. indicated that during the shift, the resident began screaming inconsolably. The resident was unable to verbalize her needs and would just state "I don't feel good." Nursing noted that the resident was redirected, given fluids and pain medication, but all interventions were ineffective. The resident continued to scream. The resident stated " I want to go to my room." The resident was placed in bed and then found on the floor out of the bed on the floor mat. Resident 71 continued screaming and showing signs of restlessness. Three staff members placed the resident back in bed. The physician was notified and an order was received to transfer the resident to the hospital.
Progress notes on January 18, 2019 at 1:17 p.m. indicated that the resident continued to scream. Resident stated " I want to go to my room". The resident was placed in bed and then found on the floor out of the bed on the floor mat. Resident 71 continued screaming and showing signs of restlessness, she then was placed back in bed by three staff members and the physician was notified and an order was received to transfer the resident to the hospital.
Nursing notes dated January 18, 2019, and timed at 12:05 p.m. indicated that the resident had been transferred to the hospital. However, nursing notes on January 18, 2019, timed at 12:55 p.m. and January 18, 2019, at 1:17 p.m. both indicated that the resident was still present in the facility at those times.
Interview with the Director of Nursing on February 22, 2019 at 11:30 a.m. she confirmed that Progress notes on January 18, 2019 at 12:55 p.m. and 1:17 p.m. failed to accurately reflect the resident's location at that time.
28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.
Previously cited: 8/17/18
28 Pa. Code 211.5 (f) Clinical records.
Previously cited: 8/17/18
| ||Plan of Correction - To be completed: 03/22/2019|
Preparation and submission of this
Plan of Correction does not
constitute admission for purposes of
general liability, professional
malpractice or any other court
F Tag 842
- Documentation related to injury of Resident 71 will be corrected by licensed staff to ensure accuracy.
- Facility will ensure clinical record documentation is complete and accurately reflects resident status.
- The Staff educator will educate licensed staff in documenting complete and accurate resident clinical records.
- The Medical Records/designee will conduct audits on 5% of the clinical records weekly x 4 weeks then every two weeks for 1 month then 5% monthly for 1 month. Variances will be addressed as identified. Results of the audits will be reported to the QAPI committee for review.