|§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 clinical records and resident interview, it was determined the facility failed to maintain accurate clinical records, consistent with professional standards and practices, for one of five sampled residents (Resident CR4).
According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient record to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care: Assessments, Clinical problems, Communications with other health care professionals regarding the patient, Communication with and education of the patient, family, and the patient's designated support person and other third parties.
According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the registered nurse was to collect complete ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals.
The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records.
A review of the clinical record Resident CR4 revealed admission to the facility on November 16, 2018, with diagnosis which, cerebral infarct (is an area of necrotic tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain) with hemiplegia and hemiparesis of the left side (hemiplegia means paralysis of one side of the body - hemiparesis means a slight paralysis or weakness on one side of the body) muscle weakness and Parkinson's Disease (disorder of the central nervous system that affects movement, often including tremors).
Nursing documentation dated January 7, 2020, at 15:35 (3:35 PM) entered as a late entry for January 6, 2020, at 13:15 (1:15 PM) by Employee 1, RN (registered nurse), indicated that she was called to Resident CR4's room by Employee 3 (a Licensed Practical Nurse) after the resident was "lowered to the floor," by Employee 2, a nurse aide, after a transfer attempt.
Employee 1 documented that the resident denied any injuries at the time, his legs were equal in length with no external rotation. The resident was assisted back to bed with the hoyer lift and denied pain. Neuro checks were within normal limits for the resident.
A review of the statement completed by Employee 2 regarding the incident dated January 7, 2020, revealed that he stated that he proceeded to get the resident ready for the "morning shift" and "the resident was then washed up and dressed for the morning." Employee 2 stated "I placed the resident's sneakers on his feet as part of the procedure. I then proceeded to get the resident ready for transfer. I pulled the wheelchair next to the bed. The brakes were locked on the chair." I proceeded to transfer. The chair kicked back from the resident. I proceeded to place the resident on the floor. I was in front of the resident and lowered him to the floor."
According to review of Employee 3's statement, he was called to the resident's room after the incident. He stated that the nurse aide, Employee 2, who was providing the resident's morning care, stated that he was transferring the resident and the wheelchair shifted, and the resident was placed on the floor. He stated an assessment was completed by the Registered Nurse supervisor on the shift (identified as Employee 1) and the resident offered no complaints of pain or discomfort. The resident was lifted back to bed with the hoyer lift. He stated that "later on, around lunch time" the resident complained of leg and hip pain.
Review of the resident's clinical record revealed that Employee 3 documented on January 6, 2020, at 15:16 (3:16 PM) that he was called to the resident's room by an aide who alleged that the resident had to be lowered to the floor after the resident's wheelchair "rolled back." The resident then offered complaints of left hip and leg pain.
A review of the facility investigation into the incident revealed Employee 3 documented that the incident occurred on January 6, 2020, at 12:52 PM.
The investigative report revealed no reference to an amended time, which would reflect that the incident had occurred much earlier based on the statements from Employee 2 and Employee 3.
Employee 4, RN, documented on January 6, 2020 at 15:19 (3:19 PM), that she was assessing the resident post fall. The nurse documented that the resident had complaints of pain to the left back and hip area with guarding to the left side. A review of Employee 4's statement, conducted on January 30, 2020, revealed that she assessed the resident after Employee 3 told her the resident was complaining of pain.
The x-ray was completed and the results received at 8:45 PM on January 6, 2020, revealing that a suspected undisplaced fracture of the left femur (thigh bone). The resident was admitted to the hospital on Janaury 7, 2020, with a minimal non-displaced (the bone cracks either part or all of the way through, but does move and maintains its proper alignment) fracture base of left femoral neck (femoral neck fracture is one type of hip fracture. This injury occurs just below the ball of the ball-and-socket hip joint, the region of the thigh bone called the femoral neck. A femoral neck fracture disconnects the ball from the rest of the thigh bone (femur).
On January 7, 2020, the Director of Nursing Services electronically reported to the State Survey Agency, that on January 6, 2020, at approximately 1:00 p.m. the resident was involved in this transfer incident and was transferred to the hospital.
An interview was conducted with Resident CR4 on January 28, 2020, at 3:18 PM following his admission to another skilled nursing facility, after his hospital stay, for treatment of the fracture. A review of the resident's admission MDS Assessment dated January 20, 2020, revealed that the resident was cognitively intact with a BIMS score of 13.
When interviewed at 3:18 PM on Janaury 28 2020, the resident confirmed that he had fallen on January 6, 2020, during morning care. The resident estimated the fall to have occurred at approximately 7:30 a.m. that morning, and was able to detail the circumstances and identify the caregiver involved(Employee 2) by name. The resident stated that he began to have severe pain around lunch time and told the nurse. The resident confirmed that he had an XRAY and was transferred to the hospital once the results were received, which he recalled was about 8:30 p.m. on January 6, 2020.
The facility failed to ensure that the resident's clinical record accurately reflected the care and services provided to the resident. The licensed nurses failed to document the accurate time of the incident in both the clinical record and facility investigation into the incident to provide an accurate time line of the occurrence and the timeliness of the care and services provided to the resident after the fall with serious injury.
28 Pa. Code 211.5 (f)(g)(h) Clinical records.
Previously cited: 6/21/19, 2/16/19.
28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing services.
| ||Plan of Correction - To be completed: 02/26/2020|
Unable to correct for resident CR4 has been discharged. Unable to retroactively document.
Residents' clinical records will be reviewed to ensure the clinical record accurately reflects the care provided to the resident involving Incidents and Accidents with the actual or approximated time of the incident recorded in the medical record or the facility investigation.
Residents' clinical records will be reviewed at the morning clinical meeting to ensure the clinical record accurately reflects the care provided to the resident involving Incidents and Accidents with the actual or approximated time of the incident recorded in the medical record or the facility investigation. Licensed nursing staff will receive education on their responsibility for accurate and timely documentation as directed per PA code Professional/Vocational standards and principles of documentation.
Random audits will be conducted in the morning clinical meeting with IDT members on nursing documentation to ensure residents clinical record accurately reflects care and services provided in a timely manner with the actual or approximated time of the incident. The results of the audits will be reviewed by the QAPI committee to determine the need for further audits, education and/or recommendations.