|§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 clinical record reviews and staff interview, it was determined that the facility failed to maintain clinical records which are complete and accurate for three of three Resident records reviewed (Residents 1, 2 and 3).
Review of Resident 1's current physician orders revealed diagnoses which included, Dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), Epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness or convulsions associated with abnormal electrical activity in the brain).
Review of resident 1's care plan revealed a focus area for alteration in bowel and bladder function (frequently incontinent). An intervention in the care plan is to provide assistance to the toilet and encourage resident to be as independent as able.
Documentation for incontinence care revealed that from the time period of September 1, 2019 to October 9, 2019, there are 24 shifts for which there is no documentation of care.
Review of Resident 2's current physician orders revealed diagnoses which included Cerebral Palsy (a group of disorders that affect movement and muscle tone or posture).
Review of resident 2's care plan revealed a focus area for alteration in bowel and bladder function, lacks ability to know when she needs to toilet. An intervention in the care plan is to check and change and to provide assistance to the toilet.
Documentation for incontinence care revealed that from the time period of September 1, 2019 to October 9, 2019, there are 25 shifts for which there is no documentation of care.
Review of Resident 3's current physician orders revealed diagnoses which included unspecified psychosis (delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior about which there is inadequate information to make a specific diagnosis) and overactive bladder.
Review of resident 3's care plan revealed a focus area for incontinence of urine and bowel Interventions in the care plan include to provide assistance to the toilet as needed and to provide incontinence care as needed.
Documentation for incontinence care revealed that from the time period of September 23, 2019 to October 9, 2019, there are 18 shifts for which there is no documentation of care.
During an interview with the Director of Nursing on October 9, 2019, at approximately 2:30 PM, regarding the missing documentation of incontinence care, she stated that documentation should be done when care is given.
28 Pa. Code 211.5(f) Clinical records.
| ||Plan of Correction - To be completed: 10/25/2019|
1. R1, R2, and R3 were assessed and were not found to have any adverse effect from the missing bowel and bladder continence documentation.
2. A review has been completed of current residents to ensure there are no adverse effects from missing bowel and bladder documentation.
3. The certified nursing assistants and licensed staff have been educated on the policy for completing their documentation timely.
4. The Director of Nursing or designee will audit 10 random bowel and bladder continence records for completion weekly x 4 weeks, then monthly x 2 months. Findings will be discussed with the interdisciplinary team at QAPI monthly.
5. Date of compliance is October 25th, 2019.