|§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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents' medical records were complete and accurately documented for one of 61 residents reviewed (Resident 19).
The facility's policy regarding gastrostomy tube feedings (the delivery of a nutritional formula through a tube that has been surgically inserted through the abdomen into the stomach), revised January 22, 2019, indicated that staff were to document the method of feeding (continuous or bolus), the name of the formula, the amount/volume in milliliters, and the time of day the formula was administered in the resident's clinical record.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated November 13, 2018, revealed that the resident had a gastrostomy tube. Physician's orders, dated September 19, 2018, included orders for the resident to receive one container (237 milliliters) of Jevity 1.5 (a specific tube feeding formula) via the gastrostomy tube five times a day (5:00 a.m., 10:00 a.m., 1:00 p.m., 6:00 p.m. and 11:00 p.m.).
Tube feeding documentation records for Resident 19, dated January 23 through February 4, 2019, revealed that staff documented that Resident 19 received continuous tube feedings, as opposed to bolus tube feedings, on January 23, 24, 25, 29 and 30, and February 2, 3 and 4, 2019. The amount of tube feeding formula administered was documented as 474 milliliters (ml) on February 1, 2019, at 2:05 p.m. and February 5, 2019, at 2:22 p.m.
Interview with Registered Nurse 8 on February 6, 2019, at 1:37 p.m. confirmed that Resident 19 did not receive continuous tube feedings and the clinical record entries that indicated the tube feeding was continuous were not accurate. She also confirmed that one container of Jevity 1.5 tube feeding formula contained 237 ml and the clinical record entries that indicated that 474 ml was administered were not accurate.
Interview with the Director of Nursing on February 6, 2019, at 4:40 p.m. revealed that in January 2019, it was identified that there were issues with how tube feedings were documented and all staff were re-educated on proper documentation between January 14 through 31, 2019. However, she had not yet completed any audits to determine if the education was effective. She confirmed that errors were made regarding the documentation of Resident 19's tube feedings.
42 CFR 483.20(f)(5), 483.70(i)(1)-(5) Resident Records - Identifiable Information.
28 Pa. Code 211.5(f) Clinical records.
Previously cited 3/15/18.
| ||Plan of Correction - To be completed: 04/01/2019|
A. The facility cannot correct the deficient practice related to inaccurate documentation by nursing staff of the bolus feedings for Resident 19. Assessment of the errors and documentation process indicated that the staff were creating errors due to their incorrect use of the documentation tool in the point of care portion of the record and entering incorrect quantities when carrying info to this tool after being viewed in the treatment administration record.
B. The facility cannot correct the deficient practice of prior incorrect documentation of administered tube feedings for any other residents. The dietitian in conjunction with the Medical Director will review records of residents receiving tube feedings to ensure documentation reflects proper nutrition and fluids were administered and residents did not suffer negative consequences of the documentation errors.
C. The Nurse Managers will develop and train staff on a simplified process for documentation and recording quantities to ensure correct documentation of all resident tube feedings. Currently, documentation occurs in the Medication Administration Record (MAR) and a point of care tasks form causing discrepancies in recording the correct information on the tasks as appears in the MAR. New process will entail all documentation being made to MAR without need for duplicate entries of volumes administered. Licensed Nursing staff will receive education on the facility procedures for proper administration and documentation protocols for tube feedings.
D. The Nurse Managers or designee will monitor treatment administration records for residents receiving tube feedings to ensure timely and complete documentation of all administered feedings. Monitors will cover 3 residents per week for 12 weeks and periodic audits on an ongoing basis. The Dietitian will monitor residents on an ongoing basis to review feedings and fluids administered to ensure optimal services to the resident.
E. Beginning March 26, 2019 and monthly thereafter, reports for monitors related to documentation of tube feeding administration will be reviewed by the Quality Assurance and Performance Improvement Committee