§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-
(i) Complete;
(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.
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Observations:
Based on review of clinical records and resident and staff interview, it was determined that the facility failed to ensure accurate and complete clinical documentation for three of 17 residents reviewed (Residents 2, 8, and 10).
Findings include:
Interview with Resident 8, on March 26, 2024, at 9:15 AM revealed that she continues to have issues with staff not "washing her up" in the mornings. Resident 8 indicated that she is incontinent overnight, and that nursing staff will not wash her properly in the morning but only hand her a washcloth and tell her to wash her face, then dress her. Resident 8 indicated that it happened this morning and keeps happening.
Review of a grievance filed February 20, 2024, indicated that Resident 8 was not "washed" and that the nurse only dressed her. A grievance filed on March 19, 2024, again indicated that Resident 8 "laid in piss all night" and that she was not washed up this morning and that it "has been happening all week."
Review of Resident 8's clinical record revealed no documented evidence to indicate that AM care (morning care provided to get them ready for the day) is being provided. Morning care can include bathing, dressing, brushing teeth, etc. There was no documented evidence in Resident 8's clinical record to indicate that the facility made any changes to her plan of care to ensure that AM care was being provided.
Review of Resident 2's clinical record revealed a nursing intervention for Resident 2 to receive a weekly shower on Tuesdays. Review of Resident 2's shower completions from February 27, 2024, to March 26, 2024, revealed two showers were documented as "not applicable" and two showers were marked as "no." There was no documented evidence to indicate that Resident 2 received a shower in the last month.
Review of Resident 10's clinical record revealed a nursing intervention for nursing staff to complete a shower every Tuesday. Review of Resident 10's shower completions from February 29, 2024, to March 26, 2024, revealed no documented evidence to indicate nursing staff completed a shower for her.
Interview with the Administrator and Employee 4, assistant director of nursing, on March 26, 2024, at 2:30 PM confirmed the above findings.
28 Pa. Code 211.12(d)(1)(5) Nursing services
| | Plan of Correction - To be completed: 04/30/2024
The nursing assistant documentation of activities of daily living care to be provided for resident's 2, 8, and 10 have been reviewed and updated to ensure proper documentation by the nursing staff.
All residents have the potential to be affected.
Nursing assistant documentation for all residents will be reviewed and updated as necessary to ensure shower/bath, and other activities of daily living care provided, is able to be properly documented in the electronic health record.
All nursing staff will be reeducated regarding providing and documenting resident specific activities of daily living, including shower/bath.
Resident grievances are reviewed at daily interdisciplinary team meeting and passed on the appropriate department for follow up and resolution. Grievance forms are then returned to the Grievance Officer to ensure the issue had been resolved.
Director of Nursing or designee will audit eight randomly selected resident records weekly x 4, then monthly x 3, for completion of documentation of activities of daily living care provided.
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