|§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 select facility policy and resident and staff interview, it was determined that the facility failed to maintain accurate clinical records of one of 12 sampled residents (Resident 17).
A review of Resident 17's admission Minimum Data Set Assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 13, 2019, revealed that the resident was always continent of bowel and bladder. The resident's admission MDS assessment also revealed that the resident's BIMS score (Brief Interview for Mental Status- a tool to assess cognitive function) score was 15, indicating that the resident was cognitively intact.
A review of Resident 17's activity of daily living documentation for the month of October 2019 revealed that the resident was frequently incontinent of both urine and bowel.
A review of a 3-day bowel and bladder record dated October 3, 2019 through October 5, 2019 revealed that Resident 17 did not have an episode of incontinence.
A review of Resident 17's evaluation for continence and retraining/scheduled toileting determination dated October 7, 2019, revealed that the resident was continent of bowel and bladder and did not require a toileting program.
A review of nursing documentation dated October 6, 2019, at 4:00 p.m. revealed that the resident was continent of bladder and bowel and did not "require set up of physical help from staff for toilet use."
However, a review of Resident 17's quarterly MDS Assessment dated October 8, 2019, revealed that the resident was frequently incontinent of urine (7 or more episodes of urinary incontinence, but at least one episode of continent voiding) and bowel (2 or more episodes of bowel incontinence, but at least one episode of continent bowel).
The MDS Assessment also revealed that the resident was not on a toileting program, a toileting program was not trialed to prevent episodes of incontinence and the resident required staff supervision with set-up help only for toileting.
Interview with Resident 17 on November 26, 2019, at approximately 11:30 a.m. revealed that he does not have episodes of urinary or bowel incontinence or require staff assistance with toileting.
Interview with Director of Nursing on November 27, 2019, at approximately 1:30 p.m. confirmed that the facility failed to accurately document the Resident 17's bowel and bladder functioning and that Resident 17's activity of daily living documentation for the month of October 2019 was inaccurate.
28 Pa. Code 211.5(f)(h) Clinical records.
Previously cited 10/12/18
28 Pa. Code 211.12 (a)(d)(5) Nursing services.
Previously cited 10/12/18
| ||Plan of Correction - To be completed: 12/27/2019|
1. Resident 17s MDS was modified to reflect accurate bowel and bladder assessments. Resident 17's ADL flow records cannot be retroactively corrected. Moving forward the facility will ensure accurate ADL documentation.
2. To identify other residents that have the potential to be affected, the DON/designee completed an audit to ensure the ADL flow record accurately reflects results of completed 3 day bowel and bladder assessments. The DON/designee completed an audit MDS assessments completed over the last 30 days to ensure bowel and bladder assessments are completed accurately. No negative findings were monitored.
3. To prevent this from recurring, the DON/designee educated current licensed nursing staff and CNAs on completing the three day bowel and bladder diary and assessment. The DON/designee educated current licensed nursing staff and CNAs on accurate ADL documentation. The DON/designee educated the MDS nurse on accurate completion of bowel and bladder assessments in the MDS.
4. To monitor and maintain ongoing compliance, the DON/designee will complete 5 resident audits to review bowel and bladder assessment and ADL documentation weekly x 4 then monthly x 2.The DON/designee will audit 5 MDS assessments for accuracy of completion of bowel and bladder assessments. Any negative findings will be immediately corrected. The results of the audit will be forwarded to the facility QAPI committee for further review and recommendations.