|§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 staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 38 residents reviewed (Resident 31).
The facility's policy regarding documentation of medications and treatments, dated January 14, 2020, indicated that the individual who administered the treatment was to record the administration on the Treatment Administration Record (TAR) directly after it was administered, and at the end of each shift the person administering the treatments was to review TAR's to ensure the necessary treatments were administered and documented.
Physician's orders for Resident 31, dated January 3, 2020, included an order to cleanse the left top foot wound with normal saline solution (sterile salt and water), pat dry, apply Medihoney (a wound healing ointment) to the wound bed, apply gauze moistened with saline and cut to fit the size of the wound, cover with dry gauze, and secure with conform (a disposable stretchy gauze wrap) and tape daily.
Review of Resident 31's Treatment Administration Records (TAR's) for January 3 through February 4, 2020, indicated that staff signed that they completed a daily treatment of irrigating the left top foot wound with normal saline solution, wiping it dry with gauze, applying Medihoney to the wound bed, applying moistened gauze cut to fit the size of the wound, covering with dry gauze, and securing with conform.
Observations on February 4, 2020, at 10:09 a.m. revealed that Licensed Practical Nurse 2 completed a treatment of cleansing the two open wounds on Resident 31's left foot with normal saline solution, dabbing the areas dry with gauze, applying Medihoney to each wound base, cutting out two pieces of Systagenix Adaptic gauze (a specialized wound dressing that is impregnated with Vaseline to keep the gauze from sticking to the wound) in shapes to fit the wound beds and placing them into the wound beds, covering the wounds with a Telfa pad (a non-adherent gauze pad), and wrapping the left foot and leg with conform gauze.
Interview with Licensed Practical Nurse 2 on February 4, 2020, revealed that the Wound Clinic changed Resident 31's wound dressing orders recently to replace the moistened gauze with Systagenix Adaptic gauze to make the dressing changes less painful for the resident. She indicated that the wound clinic sent a sheet of Systagenix Adaptic gauze back with the resident after her last appointment.
A wound care treatment consult sheet, dated January 24, 2020, revealed that the resident was seen in the clinic that day and orders were given for the wound care as above, including the use of Adaptic gauze cut to fit and to be placed in each wound bed.
There was no documented evidence that Resident 31's TAR's were updated to reflect the wound dressing that was actually being completed since January 24, 2020.
Interview with the Director of Nursing on February 6, 2020, at 4:00 p.m. confirmed that Resident 31's wound care orders were changed on January 24, 2020; however, the TAR's were not updated with the current order and should have been. She confirmed that staff continued to document that they completed the daily dressing change that was ordered on January 3, 2020, even though that was not the treatment that they provided as of January 24, 2020.
28 Pa. Code 211.5(f) Clinical Records.
| ||Plan of Correction - To be completed: 03/30/2020|
Resident 31's orders were immediately fixed by the director of nursing to indicate the proper orders according to the Wound clinic and the treatment in place. Was administered to resident for pain of 7 twice, pain of 9 and pain of 5 on four separate occasions. In order to protect residents in similar situations re-education will be provided to all current licensed nurses, new nursing staff and agency staff on the correct administration of treatments according to physician orders and the importance of transcribing new orders upon return from outside consults.
An audit will be created to monitor random outside consults and new orders to include the new order and if it is in place and being followed. Folder placed in Supervisor Office where copies of the Consults will be placed and taken to Morning Meeting for review and to ensure orders are processed properly.
The Director of Nursing or Designee will be responsible to monitor entries on the audit tool. The audit will be completed weekly times four weeks and monthly times two months. All findings will be reported through the Quality Assurance Performance Improvement meetings.