§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 policy and clinical records, and staff interview, it was determined that the facility failed to maintain complete and accurate documentation for two of 20 residents reviewed (Residents R5 and Closed Record CR91).
Findings include:
Review of a facility policy entitled "Enteral Feeding Tube Policy" dated 9/2/25, indicated "Flush tube according to physician direction."
Review of a facility policy entitled "Dietary Enteral Nutrition Care Policy" dated 9/2/25, indicated "The use of an enteral nutrition tube has a major impact on a resident and his or her quality of life. Enteral nutrition tubes will be utilized only after assessment determines that the clinical condition of the resident makes the use of the feeding tube medically necessary."
Review of a facility policy entitled "Resident Change in Condition" dated 9/2/25, indicated "The Physician/Provider and Resident/Family/Responsible Party will be notified when there has been a significant change in the resident's physical/emotional/mental condition."
Review of a facility policy entitled "Post Mortem Care Policy" dated 9/2/25, indicated "Document postmortem care, time body was released and to whom and complete the inventory of personal effects nothing final disposition of everything listed: transported with resident, sent home with family/representative, left on resident's body, or retained by the facility."
No policy provided by the facility regarding documentation.
Review of Resident R5's clinical record revealed an admission date of 1/29/25, with diagnoses that included respiratory failure (a condition where you don't get enough oxygen or you get too much carbon dioxide in your body), persistent vegetative state ( a severe brain injury condition where a person is awake, but shows no signs of awareness), and diabetes (a health condition caused by the body's inability to produce enough insulin).
Resident R5's clinical record revealed a physician's order dated 11/28/25, for enteral feeding, Free Water: Administer 200 cubic centimeter (cc) of water four times per day (QID) for total of 800cc/day. Flush tube with 60cc free water before and 30cc free water between meds. (Record amounts every shift); a physician's order dated 12/17/25, for Diabetisource AC at 100 ml per hour continuous via gastric tube x 20 hours (Up at 12:00 a.m., down at 8:00 p.m. or when total amount infused. Total volume 2000ml per day. Day =1200ml, Night=800ml).
Review of documentation of water flushes for Resident R5 from 12/1/25, through 1/10/26, under the medication administration record revealed Resident R5 received less than the ordered 200 cc of water flush QID (not counting medication flushes) fifteen times. Documentation also revealed that facility lacked any evidence of water flushes four times.
Review of documentation of formula intake for Resident R5 from 12/17/25, through 1/10/26, under the medication administration record revealed Resident R5 received less than the ordered 2000 ml of formula per day eighteen times, and more than the ordered 2000 ml of formula per day one time.
During an interview on 1/11/25, at 2:45 p.m. the Regional Director of Clinical Services confirmed that Resident R5's clinical record contained incomplete and inaccurate documentation related to his / her tube feeding formula and water flushed.
Resident CR91's clinical record revealed an admission date of 10/3/25, with diagnoses that included sepsis (a reaction to an infection that causes extensive inflammation throughout the body, potentially leading to tissue damage, organ failure, and even death), cerebral palsy (a brain disorder that appears in infancy or early childhood, permanently affecting body movement and muscle coordination. It is caused by changes in the developing brain that disrupts its ability to control movement and maintain posture and balance), and Non-ST Elevation Myocardial Infarction (NSTEMI - a type of heart attack characterized by a partial blockage of an artery that leads to a lack of blood flow to the heart muscle).
Resident CR91's clinical record progress note dated 10/20/25, at 9:10 a.m. revealed "Call to PCMA regarding elevated Temp, face flushed, decreased oral intake and lethargy." A progress note dated 10/20/25, at 11:00 a.m. revealed "New Orders received PRN (as needed) Tylenol every 6 hours, STAT chest x-ray, and lab in the morning". A progress note dated 10/20/25, at 9:34 p.m. revealed "Resident ceased to breath at 2118 (9:18 p.m.), the RN called the sister and notified her about the brother's demise. The body is to be discharged to funeral home." A progress note dated 10/20/25, at 9:45 p.m. revealed "Placed a phone call to Funeral Home, provided required information, a crew will be here shortly, the body is ready to be picked up."
Resident CR91's clinical record lacked evidence of assessment of Resident CR91's condition between 10/20/25, at 9:10 a.m. and 10/20/25, at 9:34 p.m. when Resident CR91's sister was notified of his/her passing. Resident CR91's clinical record also lacked evidence of physician notification of his/her death, physician order to release body to the funeral home, and information regarding when he/she was released from the facility to the funeral home and if any belongs were sent with him/her at the time he/she was released to the funeral home.
During an interview on 1/13/26, at 1:43 p.m. the Director of Nursing confirmed that Resident CR91's clinical record lacked any evidence of assessment of Resident CR91 on 10/20/25, between 9:10 a.m. and 9:34 p.m. when Resident CR91's sister was notified of his/her passing, physician notification of his/her death, physician order to release the body and when Resident CR91 was actually released to the funeral home and if any of his/her belongings were sent with him/her.
28 Pa. Code 211.5(f)(ii)(iii) Medical records
28 Pa. Code 211.12(d)(1)(5) Nursing services
| | Plan of Correction - To be completed: 02/10/2026
1. Resident R5's orders were clarified to separate the free water flushes, the water flush before and after medications. Resident R5 suffered no ill effects. The facility can not correct the lack of documentation in Resident CR91's chart as he is no longer at the facility.
2. Current resident's with Tube Feeding orders will be reviewed by the Dietitian for accuracy. The facility will maintain complete and accurate documentation in the resident's medical record.
3. The licensed nursing staff will be re-educated on Enteral Feeding Tube Policy, Dietary Enteral Nutrition Policy, Resident Change in Condition Policy and Post Mortem Care by the Director of Nursing/designee.
5. The dietician/designee will audit resident's with tube feedings weekly for four weeks and then monthly for two months to ensure documentation is reflective of the physician order. The director of nursing/designee will audit resident's with a change in condition to ensure documentation is reflective and proper notifications completed 5 days a week for one week, 3 days a week for one week, 1x a week for two weeks and monthly for two months. Results of audits will be submitted to the Quality Assurance Performance Improvement Committee for review and recommendations.
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