§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-
(i) Complete;
(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.
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Observations:
Based on clinical record review and staff interview it was determinied that the facility failed to ensure each resident record is complete and accurately documented for four of five residents reviewed ( Residents 2 4, 6, and 7).
Findings Include:
Review of Resident 2's clinical record revealed diagnoses that included dementia and hypertension (elevated blood pressure). Further review of Resident 2's clinical record revealed no task documentation for Resident 2's hygiene, toileting or bathing on November 5, 2021.
Review of Resident 4's clinical record revealed staff failed to document tasks related to resident care on November 5, 2021. The tasks included resident dressing and toileting.
Review of Resident 6's clinical record revealed staff failed to document tasks related to resident care on November 5, 2021. The tasks included resident dressing, hygiene, bathing and toileting.
Review of Resident 7's clinical record revealed staff failed to document tasks related to resident care on November 5, 2021. The tasks included personal hygiene and toileting.
In an email correspondence from the Nursing Home Administrator on November 24, 2021, at 2:07 PM she stated that the facility was "having spotty internet connection issues that day." No additional information was provided.
28 Pa. Code 211.5 (f) Clinical records
28 Pa. Code 211.12 (d) (5) Nursing services
| | Plan of Correction - To be completed: 12/27/2021
1. No adverse affects were found with residents R2, R4, R6 and R7 from incomplete documentation on November 5, 2021.
2. DON/Designee will conduct a facility wide audit to ensure that resident task documentation was completed for residents on November 5, 2021. If any incomplete documentation is identified, the resident(s) will be reviewed by the facility IDT for any adverse affects and corrective action will be taken.
3. Staff Development/Designee will educate nursing staff that each resident record must be completed and accurately documented daily. In the event the electronic record is not accessible, documentation will be completed on paper.
4. Staff Development /Designee will conduct 2 random audits weekly for 1 month, and then 2 random audits monthly x2, to ensure that resident task documentation has been completed. Staff Development /Designee will report audit results monthly x3 for Quality Assurance and Performance Improvement Committee to address any trends or patterns, need for further review, and or recommendations.
5. Date of compliance 12/27/21.
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