§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.
|
Observations:
Based on observations, clinical record reviews, and staff interviews it was determined that the facility failed to ensure clinical records were complete and accurately documented for three of six residents reviewed (Residents 3, 5, and 6).
Findings include:
Review of Resident 3's clinical record revealed diagnoses that included: paraplegia (paralysis of the legs and lower body caused by spinal injury), pressure ulcer on the sacral (lower back between the two hip bones of the lower pelvis) region, protein calorie malnutrition (malnourished leading to changes in body composition and function), anemia (a deficiency or red blood cells), chronic kidney disease (disease of the kidneys leading to renal failure), pressure ulcers on right and left lower back, pressure ulcer right and left hips.
Review of Resident 3's November 2021, Treatment Administration Record (documentation of treatments that have been administered) failed to document that treatments were administered or refused on November 17th, 25th, 26th, and 29th, 2021. The following treatment orders that were not documented as completed include: right hip cleanse with normal saline solution, pat dry, apply collagen (main structural protein) sheet w/ silver, cover with a silicone bordered foam dressing (a 5 layer foam dressing made with breathable film, super absorbent foam and gentle adhesive), change daily with a start date-of November 17, 2021 and a discontinued date of December 2,2021; right lateral foot cleanse with normal saline solution, pat dry, apply collagen sheet, cover with Army Battle Dressing (ABD pad-high absorbency pad/wound dressing), wrap with gauze roll, secure with tape, change daily with a start date of November 17, 2021, and discontinue date of December 2, 2021; left ischium cleanse with normal saline solution, pat dry, fill wound bed with gauze roll wet to moist with Dakin's strength solution (an antiseptic solution used to cleanse wounds in order to prevent infection), cover with an ABD pad, secure with tape, change daily, with a start date of November 6, 2021, and a discontinue date of December 8, 2021; right ischium cleanse with normal saline solution, pat dry, fill wound bed with gauze roll wet to moist with Dakin's strength solution, cover with an ABD pad, secure with tape, change daily, with a start date of November 6, 2021, and a discontinue date of December 8, 2021; and sacrum cleanse with normal saline solution, pat dry, apply Mesalt (a dressing that absorbs exudate, bacteria, and necrotic \ material and creates an environment which is unfavorable to micro-organisms maintains integrity even when fully saturated), cover with a silicone bordered foam dressing, change daily with a start date of November 17, 2021, and a discontinue date of December 2, 2021.
Review of resident 3's progress notes failed to document that the aforementioned treatments for November 17th, 25th, 26th, and 29th, 2021 were either administered or refused.
Review of Resident 5's clinical record revealed diagnoses that included: acute and chronic respiratory failure ( blood doesn't have enough oxygen or has too much carbon dioxide), morbid obesity (excessive body fat that increases the risk of health problems), congestive heart failure (weakness of the heart that leads to a buildup of fluid in the lungs and surrounding tissue), depression (feelings of severe despondency and dejection), anxiety (a feeling of worry, nervousness, or unease), and pressure ulcer right buttock.
Review of Resident 5's November 2021, Treatment Administration Record failed to document whether the following treatments were administered or refused on November 26th, 2021. The following treatment orders that were not documented as completed include: cleanse right buttocks with normal saline solution, apply collagen sheet, then cover with foam border gauze until wound team assesses, every day shift with a start date of November 22, 2021, and a discontinued date of December 6, 2021; and cleanse right lower quadrant and medial (situated in the middle) abdominal fold with normal saline solution, apply collagen and ABD pads until wound team assesses every day shift with a start date of November 22, 2021, and a discontinue date of December 6, 2021.
Review of resident 5's progress notes failed to document that the aforementioned treatments for November 26, 2021 were either administered or refused.
Review of Resident 6's clinical record revealed diagnoses that included: osteomyelitis (inflammation of bone or bone marrow usually due to infection), pressure ulcer right heel, pressure ulcer right elbow, anxiety (a feeling of worry, nervousness, or unease), heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), bipolar (a mental health condition alternating periods of elation and depression), anemia (a deficiency or red blood cells), cerebrovascular accident (stroke- damage to the brain from interruption of its blood supply), and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs and facial muscles).
Review of Resident 6's November 2021, Treatment Administration Record failed to document whether the following treatment was administered or refused on November 30th, 2021. The following treatment orders that were not documented as completed include: cleanse the pressure wound on right medial heel with normal saline solution, pat dry, apply gauze wet to moist with betadine (an antiseptic used for skin disinfection), cover with an ABD pad, wrap with gauze roll, secure with tape, change daily every evening shift for wound care with a start date of October 26, 2021.
Review of resident 6's progress notes failed to document that the aforementioned treatment for November 30, 2021 was either administered or refused.
During an interview with the Director of Nursing on December 10, 2021, at approximately 2:15 PM it was revealed that the aforementioned treatments should have been documented whether they were administered or refused.
211.12 (d)(1)(5) Nursing Services
| | Plan of Correction - To be completed: 01/05/2022
The wound team has assessed R3, R5 and R6 and no adverse outcomes identified as result of missed documentation.
An initial audit will be completed of current residents receiving wound treatments to ensure proper documentation was completed on the Treatment Administration Record for the past 15 days.
Director of Staff Development/Designee will educate licensed nurses on documentation of treatment per Treatment Administration policy to ensure compliance.
Director of Nursing/Designee will conduct random audits of 10 residents Treatment Administration Record per week for 4 weeks and then monthly for 2 months to ensure compliance.
Results of the audits will be presented at the monthly Quality Assurance and Performance Improvement Meeting for further review and/or recommendations
|
|