|§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, observations, and resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurate for two of 25 resident records reviewed (R47 and R129).
Review of Resident R47's clinical record revealed diagnoses including Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), unspecified psychosis (a mental disorder characterized by a disconnection from reality), cerebra vascular accident (damage to the brain from interruption of its blood supply).
On February 22, 2019, at 9:32 a.m. review of R47's electronic physician order dated February 8, 2019, revealed an order for 'Full Code' (full code would prompt immediate life-saving emergency procedure - cardiopulmonary resuscitation -CPR). Review of R47's paper chart (medical record stored at the nursing station) revealed a POLST (Pennsylvania Orders for Life-Sustaining Treatment- a form that specifies the types of medical treatment that a patient wishes to receive towards the end of life) dated February 18, 2019, which read "DNR" (Do Not Resuscitate, or allow natural death).
Review of Resident R129's clinical record revealed diagnoses including unspecified psychosis, chronic kidney disease, major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).
On February 22, 2019, at 11:41 a.m. review of R129's electronic physician order dated February 27, 2017, revealed an order for 'full code.' Review of R129's hard chart (medical record stored at the nursing station) revealed a POLST, undated that read 'DNR.'
Interview with the Assistant Director of Nursing on February 22, 2018, at approximately 10:05 a.m. revealed that the facility expectation was that all code status information would be updated and should match both in the electronic record and the hard charts.
The facility failed to maintain complete and accurate clinical records for two residents.
Resident Records - Identifiable Information
CFR(s): 483.70(i)(1)-(5) Previously cited 04/23/18, 08/23/17, 04/20/17
28 Pa. Code 211.5(f) Clinical records
Previously cited 04/23/18, 08/23/17, 04/20/17, 01/04/17
| ||Plan of Correction - To be completed: 05/01/2019|
Residents 47 and 129 charts updated to reflect current code status.
Staff will be educated to ensure clinical records reflect the current code status of residents
Social Service/designee will audit residents' charts to ensure current code status is reflected.
During care conferences social services will update chart with any changes.
NHA/designee will do random audits following comprehensive assessments weekly x 1 month then Monthly x 3.