Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
Inspection Results For:

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Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification, Civil Rights Compliance and State Licensure Survey completed on October 8, 2019, it was determined that Townview Health and Rehabilitation Center was not in compliance with the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

 Plan of Correction:

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
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.

Based on clinical record review and and staff interview, it was determined that the facility failed to ensure that clinical records were complete and accurate for one of two resident closed records reviewed. (Resident CR101).

Findings include:

A review of the closed clinical record for Resident CR101 indicated that she was admitted to the facility on 11/2/18, with diagnoses that included pulmonary hypertension (high blood pressure that affects arteries in the lungs and the heart), atrial fibrillation (irregular heartbeat), cardiomegaly (enlarged heart), tricuspid valve insufficiency (heart valve does not close properly), diabetes mellitus, cardiac arrest (sudden loss of heart function) and sleep apnea (sleep disorder in which breathing stops and starts).

A review of the quarterly Minimum Data Set (MDS - periodic assessment of care needs) dated 7/4/19, indicated that Resident CR101 understand others.

During a review on 10/7/19, at 2:00 p.m. of the closed clinical record for Resident CR101 indicated that the resident ceased to breath on 8/20/19 and the clinical record did not include further documentation of Resident CR101's death.

During an interview on 10/7/19, at 5:00 p.m. the Director of Nursing confirmed that facility staff failed to maintain complete and accurate documentation in the clinical record for Resident CR101.

28 Pa. Code:211.5(f) Clinical records.

28 Pa. Code: 211.12(d)(1)(5) Nursing services.

 Plan of Correction - To be completed: 11/15/2019

What corrective action will be accomplished for those residents found to have been affected by the deficient practice?
Late entry will be entered in the resident's record by the nurse who was on duty describing the resident's death.

How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
All residents who have CTB in the last 90 days will have their record reviewed to ensure accuracy of documentation describing their death. Late entries will be written by the nurse on duty if lack of documentation exists.

What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur?
Documentation guidelines/procedure established for outlining the minimum required documentation for deceased residents. Nursing staff will be educated on documentation guidelines/procedure for deceased residents.

How will the corrective action be monitored to ensure that the deficient practice will not recur?
Starting 10/21/2019 all residents who CTB will have nursing notes audited to ensure appropriate documentation related to death for 3 months. Non-compliance will be addressed immediately. Results will be reported to the QA committee.

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