|(i) Medical records. |
(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
(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the residentís 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) Physicianís, nurseís, and other licensed professionalís progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under ß483.50.
Based on clinical record review, it was determined that the facility failed to maintain complete clinical records for eight of fifteen sampled residents. (Residents R18, R59, R88, R92, R98, R115, R116, R118)
Clinical record review revealed that Resident R18 had diagnoses that included constipation and dysphagia. Physician's orders for February 2017 directed staff to provide a medication for constipation (Senokot), a nutritional supplement (house shake), and additional fluids to prevent dehydration. Staff failed to document on the Medication Administration Record (MAR) the administration of the constipation medication on February 11, 2017, the health shake on February 1, 2, 3 and 4, 2017, and if additional fluids were provided on February 4 and 9, 2017, in accordance with the physician's orders.
Clinical record review revealed that Resdient R59 had diagnoses that included diabetes mellitus, constipation and osteoporosis. Physician orders directed staff to provide insulin (Novolog) daily based on the resident's blood sugar level. Review of the MAR revealed that staff failed to document Resident R59's blood sugar on February 3, 2017, and whether or not insulin was adminstered in accordance with the physician's order. Staff also failed to document on the MAR the administration of the resident's constipation medication (Senokot) on February 9, 2017, and additional fluids to be provided on the evening shift on February 8 and 9, 2017.
Clinical record review revealed that Resident R115 had a diagnosis of dementia. On December 7, 2016, physician's orders were obtained for staff to provide a nutritional supplement (health shake) three times a day and to weigh the resident on Sundays and Wednesday to address the resident's significant weight loss. A review of the February 2017 MAR revealed that staff failed to document the evening shift administration of the nutritional supplement daily from February 1 through 12, 2017, and failed to document the resident's weight on February 5 and 8, 2017 in accordance with the physician's order.
Clinical record review revealed that Resident R116 was admitted to the facility on January 30, 2017, with diagnoses that included congestive heart failure, hypertension and glaucoma. Physician's orders for February 2017 directed staff to administer a blood thinning medication (Coumadin), an antihypertensive medication (Metoprolol) and a medication to treat glaucoma (Lumigan). Review of the MAR revealed that staff failed to document the administration of the blood thinning medication on February 11, 2017 and the antihypertensive and glaucoma medications on February 7, 2017.
Clinical record review revealed that Resident R92 was admitted to the facility on August 9, 2014 with diagnoses that included hemiplegia and hemiparesis, atrial fibrilliation, congestive obstuctive pulmonary disease, and vascular dementia. Physician's orders for February 2017 directed staff to turn and reposition every two hours around the clock. Review of the Treatment Administration Record (TAR) revealed that from February 1, 2017 to February 12, 2017 there was a lack of documentation to support that staff carried out this order.
Clinical record review revealed that Resident R98 was admitted to the facility on October 8, 2009 with diagnoses that included Parkinson's Disease, pressure ulcer to right buttock, glaucoma and hypertension. Physician's orders for Februaury 2017 included for staff to apply Calmoseptine ointment to the resident's buttock and periarea every shift. Review of the TAR revealed that staff failed to document the use of the ointment on February 1,2, 2017 on the 11p.m. to 7a.m. shift and on February 1,2,4,6,7,8, on the 7a.m, to 3p.m. and on February 4,6, 2017 on the 3p.m. to 11p.m. shift.
Clinical record review revealed that Resident R88 was admitted to the facility on April 9, 2015 with the diagnoses of cerebral vascular disease, aphasia, atrial fibrilliation, and obesity. Physician's orders for February 9, 2017 directed staff to apply Triamcinolone cream twice daily for two weeks. Staff failed to document that this was done on 7a.m. shift on February 9,10, 11, 12, 2017.
Clinical record review revealed that Resident R118 had diagnoses that included cerebral vascular disease, hemiplegia, aphasia, and congestive obstructive pulmonary disease. Physician's orders for February 2017 directed staff to apply Triamcinolone cream to buttocks and upper back twice daily. Staff failed to document the application of this cream at 9:00 a.m. on February 1, 2, 4, 6, 7, 8, 9, 10, 11, 12, 2017.
28 Pa. Code 211.5(f) Clinical records.
Previously cited 12/16/16
| ||Plan of Correction - To be completed: 02/23/2017|
The Provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the Statement of deficiencies.
1. It is the practice of this facility to maintain complete and accurate clinical records. R18, R59, R88, R92, R98, R115, R116, R118 records were reviewed and physicians were contacted and omissions reviewed.
2. Director of Nursing /Designee re-educated licensed nursing staff on maintaining accurate and complete clinical records.
3. Director of Nursing / Designee will complete daily random audits to ensure compliance.
4. Director of Nursing will report audit trends to QAPI Committee for review. QAPI Committee will determine compliance and need for further audits.