§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(h) Medical records.
§483.70(h)(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(h)(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(h)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.
§483.70(h)(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(h)(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, clinical records and staff interview, it was determined that the facility failed to make certain that medical records on each resident are complete and accurately documented for one of four residents (Resident R69)
A review of the facility policy "Administration Procedures For All Medications" dated 4/1/25, indicated medications will be administered in a safe and effective manner and after administration document in the MAR (medication administration record) or TAR (treatment administration record) as necessary.
A review of the clinical record indicated that Resident R69 was admitted to the facility on 1/6/24, with diagnoses that included heart disease, dementia, and asthma.
A review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 5/13/25, indicated the diagnoses remained current.
A review of Resident R69's physician orders dated 1/23/25, indicated to administer oxygen via n/c (nasal cannula) at 4L (liters) per minute continuously every shift.
A review of Resident R69's MAR dated May 2025 did not include documentation that the resident received oxygen as ordered on 5/4, 5/9, 5/13, 5/14, 5/15, 5/20, 5/22, 5/23, and 5/27/25.
During an interview on 5/28/25 , at 1:45 p.m. the Nursing Home Administrator confirmed the above findings, and the facility failed to make certain that medical records on each resident are complete and accurately documented for Resident R69.
28 Pa. Code: 211.5(f)(g)(h) Clinical records.
| | Plan of Correction - To be completed: 06/25/2025
No adverse outcome occurred from resident R69 having missed documentation for oxygen administration.
Each shift RN supervisor will monitor MAR/TAR completion by utilizing the Point Click Care Dashboard to check compliance before the shift is over.
The Director of Nursing will complete RN supervisor education on documentation monitoring and licensed staff education on completing MAR/TAR documentation before the end of their shift.
The Director of Nursing/designee will audit MAR/TAR documentation completion five days a week for four weeks to ensure there are no missing entries.
Audits will be taken to QAPI for review/discussion.
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