|§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 policy review, clinical record review and staff interview, it was determined the facility failed to ensure that clinical records were complete and accurate for one of 24 residents reviewed (Resident 136).
Review of facility policy Weight Assessment and Intervention, effective date February 2019, revealed that when obtaining a resident's weight, staff would reweigh the resident if there was a 5 pound or more difference noted to verify the resident's weight before documenting it in the resident's record.
Review of Resident 136's weights revealed that on April 9, 2019, the resident was documented as weighing 207.4 pounds. On April 23, 2019, the resident was documented as weighing 262.2 pounds, a difference of 54.8 pounds. Further review of Resident 136's record failed to reveal that the resident was reweighed following the April 23, 2019 weight.
Interview with licensed nurse Employee E3 on April 26, 2019 at 9:30 a.m. confirmed that Resident 136's weight of 262.2 pounds on April 23, 2019 was documented in the clinical record incorrectly.
28 Pa. Code 211.5 (f) Clinical records
Previously cited 3/18/18
28 Pa. Code 211.12 (d)(1)(5) Nursing services
Previously cited 3/18/18
| ||Plan of Correction - To be completed: 06/10/2019|
1. Resident 136 did not have any complications, weight updated and current no weight gain noted.
2. Current residents in-house will have weight done as per weight policy; weights will be reviewed for accuracy/completion by DON or designee.
3. All nursing staff will be in-serviced on the weight policy
4. Weekly audits x 4, then monthly x 4 reviewing all weights to ensure weights are timely and accurate by DON or designee. Results of these audits will be reviewed at QAPI for further recommendations as indicated.