|§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 clinical record review and staff interview, it was determined that the facility failed to document and maintain clinical records that were complete for three of seven sampled residents. (Residents 1, 2, 3)
Clinical record review revealed that Resident 1 was admitted to the facility on May 30, 2019, with diagnoses that included dementia and dysphagia (difficulty or discomfort in swallowing). On December 28, 2019, the physician directed staff to administer a tube feeding every day along with a water flush every four hours. The time of the flush was to be 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM and 8:00 PM. Review of the Medication Administration Record (MAR) for January 2020, revealed that the water flush was not documented as being administered on January 8, 2020, at 12:00 AM and 4:00 AM, on January 10, 2020, at 12:00 PM, and on January 14, 2020, at 8:00 AM and 12:00 PM.
Clinical record review revealed that Resident 2 was admitted to the facility on December 22, 2017, with diagnoses that included dysphagia. On November 10, 2019, the physician directed staff to administer a water flush through his feeding tube every six hours. The time of administration was to be 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM. Review of the MAR for January 2020, revealed that the water flush was not documented as being administered on January 1, 2020, at 12:00 AM, on January 6, 2020, at 6 AM and 12:00 AM, on January 9, 13, 17, 21, and 27, 2020, at 12:00 AM.
Clinical record review revealed that Resident 3 was admitted to the facility on April 26, 2018, with diagnoses that included dysphagia. On January 6, 2020, the physician directed staff to administer a tube feeding along with a water flush through his tube every six hours. The time of administration was to be 12:00 AM, 6:00 AM, 12:00 PM, 6:00 PM. Review of the MAR for January 2020, revealed that the water flush was not documented as being administered on January 14 and 18, 2020, at 12:00 PM, and on January 19, 2020, at 12:00 PM and 6:00 PM.
In an interview on January 28, 2020, at 2:06 p.m., the Director of of Nursing confirmed that the nursing staff failed to document that the water flushes were completed as ordered by the physician.
28 PA. Code 211.5(f) Clinical records.
| ||Plan of Correction - To be completed: 02/18/2020|
Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.
1).Residents 1, 2 and 3 identified and no ill-effects noted.
2). To identify other residents with potential to be affected a review of all residents completed to identify residents requiring tube feed flushes.
3). To prevent reoccurrence, charge nurses were re-educated to document on MAR after administering tube flushes.
4). Unit Managers/designee to audit MAR's tube flush daily for two weeks, five times a week for four weeks,then three times a week for four weeks.
5). Results will be presented at QAPI for three months.