|§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 medical record review, video footage review and staff interview, it was determined that the facility failed to maintain complete and accurate medical records related to medication administration documentation and controlled substance records for one of 25 residents reviewed (Resident R22).
Review of the medical record for Resident R22 revealed an admission Minimum Data Set assessment (MDS - a mandatory periodic resident assessment tool), dated March 9, 2019, indicating the resident was admitted to the facility on March 2, 2019.
Review of the medical record for Resident R22 revealed the resident died while a resident in the facility and was pronounced dead on March 29, 2019, at 8:39 p.m.
Review of facility video footage for March 29, 2019, at 6:34 p.m. and 6 seconds revealed Employee E7, Registered Nurse (RN) entering Resident R22's room with intravenous fluids for Resident R22 and exited the room eight minutes and 42 seconds later.
Interview with Employee E7, RN, on April 4, 2019, at 1:20 p.m. revealed that when she went into Resident R22's room on March 29, 2019, with intravenous fluids and connected them to the resident.
Review of the Medication Administration Record (MAR) audit report for Resident R22 revealed that the physician's order for sodium chloride solution 0.9% was not signed off as administered until March 30, 2019, at 1:33 a.m. which was not at the time the medication was administered and was also after the resident had died. The audit report also revealed that the medication was not signed out as administered by the nurse who hung the medication (Employee E7, RN) but was signed out by the nursing supervisor (Employee E17, RN).
Review of the March 2019 MAR for Resident R22 revealed two physician orders for alprazolam 0.25 mg tablets, 1 tablet via tube every six hours as needed for anxiety. The first order was for March 13 to 21, 2019, inclusive and the second order was for March 21 to March 27, 2019, inclusive. Review of the electronic MAR revealed administrations of this medication on three occasions (two administrations on March 14 and one on March 17, 2019).
Review of the paper-based controlled medication utilization record for Resident R22 for March 13 to 27, 2019, revealed nine administrations of alprazolam on:
- March 14, 2019, at 2:00 a.m. (documented in electronic MAR);
- March 14, 2019, at 1:00 p.m.;
- March 14, 2019, at 9:00 p.m. (documented in electronic MAR);
- March 14, 2019, at 4:00 a.m. (duplicate date);
- March 17, 2019, at 4:30 p.m. (documented in electronic MAR);
- March 21, 2019, at 10:47 a.m.;
- March 24, 2019, at 9:00 a.m.;
- March 26, 2019, at 9:00 p.m., and
- March 27, 2019, at 9:00 p.m.
The facility failed to maintain complete and accurate medical records related to medication administration documentation and controlled substance records.
28 Pa. Code 211.9(a)(1) Pharmacy services
28 Pa. Code 211.5(f) Clinical records
28 Pa. Code 211.12(d)(1)(5) Nursing services
| ||Plan of Correction - To be completed: 05/24/2019|
Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.
All nursing professionals have been reeducated on effectively maintaining complete and accurate medical records related to medication administration documentation.
Random audits of MAR's will be conducted weekly x 4 months by the DON or designee.
Findings of audits will be reported to the QAPI committee who will determine the need for further audits.
This process will be overseen by the DON