§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 facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for one of six residents reviewed (Resident 2).
Findings include:
The facility's policy regarding charting and documentation, dated January 1, 2023, indicated that the following information was to be documented in the resident medical record: Objective observations, changes in a resident's condition, treatments and services performed, and events, incidents, or accidents involving the resident.
An admission summary note, dated January 15, 2024, indicated that Resident 2 was admitted on January 14, 2024. The resident was alert and oriented to person, place and time.
A social service note for Resident 2, dated January 18, 2024, indicated that the facility received a call late at night regarding the resident sitting on a bed pan for four hours. Resident 2 told staff she was put on the bed pan but was not removed from it for four hours. Resident 2 stated she did not use her call light to get help, and she yelled for an employee. The resident was educated on importance of using her call light in time of need.
Information reported to the Department of Health on January 18, 2024, indicated that Resident 2's family member called the facility and reported that she was left on a bed pan.
There was no documented evidence in the medical record that Resident 2 was assessed by a registered nurse or that a skin assessment was completed by staff.
Interview with the Assistant Director of Nursing on January 24, 2024, at 12:50 p.m. revealed that she assessed Resident 2 with the supervisor on duty; however, the assessment was not documented in the medical record.
28 Pa. Code 211.5(f) Clinical Records.
28 Pa. Code 211.12(d)(5) Nursing Services.
| | Plan of Correction - To be completed: 03/13/2024
Resident R2 continues to reside at the facility and is in stable condition. Resident R2 skin assessment documentation was entered into the point click care software program as a late entry.
The director of nursing and/or designee will audit all facility incidents and accidents during the previous fourteen days to identify any residents with missing documentation of a physical assessment and provide immediate education to nursing staff should findings arise.
The director of nursing and/or designee will provide education to current licensed nursing staff on the charting and documentation policy. Any new or agency licensed staff will receive education on facility policy as a part of their orientation to the facility.
The director of nursing and/or designee will audit facility incident and accident reports to ensure that complete and accurate data is present and documented in the medical record x thirty days, then weekly x four weeks, then monthly x three months. The results of these audits, along with a root cause analysis of any identified issues will come to the Quality Assurance Performance Improvement Committee for further analysis and recommendations.
In preparation and/or execution of this plan of correction documentation does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.
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