|§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 staff interviews, it was determined that the facility failed to maintain and complete accurate documentation for one of 27 residents reviewed (Resident R32).
Review of Resident R32's clinical record revealed the resident was admitted on March 20, 2017, with a diagnosis to include seizure disorder (abnormal electrical activity in the brain).
Review of Resident R32's clinical record nurse progress notes revealed the resident had a fall on January 18, 2019, where the resident was found on the floor.
A request was made on February 15, 2019, at 2:30 p.m. for a facility investigation regarding the resident's fall on January 18, 2019.
Interview on February 19, 2019, at 9:00 a.m. with the administrator, where she stated that Resident R32 did not have a fall on January 18, 2019, and she stated that facility nursing staff had documented in the wrong clinical record regarding the fall.
The facility failed to maintain and complete accurate documentation
28 Pa. Code: 211.5(f)(g)(h) Clinical records.
| ||Plan of Correction - To be completed: 03/11/2019|
Documentation competency developed and initiated on 2/25/2019 for all staff who document in the EMR/medical record. Education will be conducted annually and as needed.
Signage placed in each team room/nurses station to remind staff to select the correct resident before starting documentation (2/20/2019)
Monthly monitor established to review chart documentation for accuracy/ any errors in documentation. Items to be assessed are correct identification of resident, content, grammar and accuracy of progress note. Responsibility of DON. Monitor to be maintained monthly for 6 months and if 100% accuracy will continue quarterly