§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(h) Medical records.
§483.70(h)(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(h)(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(h)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.
§483.70(h)(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(h)(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 review of clinical records and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for one of three residents reviewed (Resident 3).
Findings include:
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated April 29, 2025, indicated that the resident was cognitively impaired, was dependent on staff for daily care tasks, and had a history of falls.
A nursing note for Resident 3, dated May 19, 2025, at 4:47 p.m. revealed that it was a follow-up to a fall earlier in the day, and the resident was now complaining of shoulder pain.
Facility investigation documents for Resident 3 revealed that the resident fell on May 19, 2025, at 9:00 a.m. and had a skin tear on the back of the left hand. The investigation document included an assessment of the resident's fall and injury; however, there was no documented evidence of this assessment in the resident's clinical record.
Interview with the Nursing Home Administrator on May 28, 2025, at 11:27 a.m. confirmed that although a registered nurse assessed Resident 3 on May 19, 2025, at 9:02 a.m. and documented the assessment in the investigation documents, the investigation documents were not part of the resident's clinical record.
28 Pa. Code 211.5(f) Clinical Records.
28 Pa. Code 211.12(d)(1) Nursing Services.
| | Plan of Correction - To be completed: 06/30/2025
Investigation was immediately completed by Nursing Home Administrator and Director of Nursing, it was identified that the Electronic Medical Record failed to populate a progress note from the Incident Report as a standard technology set up within the Electronic Medical Record. The nursing note from the incident report was manually placed into the progress note.
Recent resident incident reports were reviewed and audited to ensure that the accurate population from the incident report into the progress note. All falls were populated into a progress note .No additional technological errors noted. This issue has been considered per Laurel View and Point Click Care (electronic medical records software used by the facility) as a single isolated technological failure.
To ensure a quality check is placed to monitor technological error. An additional check has been placed on the complete investigation audit form for falls that is reviewed and completed by healthcare leadership as a quality check to ensure that the documentation populates into the progress note. If noted that it has not, the note will be manually placed within the progress notes section of Point Click Care.
Incident Report policy was reviewed and updated by the Nursing Administration.
This Policy will be educated and reviewed with All current Healthcare Registered Nursing and Quality Assurance Team Members and acknowledgements will be obtained and documented. All newly hired staff as well as temporary (agency) staff are to be educated on Quality Check placed on Incident Reports
The Director of Nursing, Assistant Director of Nursing, Healthcare Nursing Leadership, or designee will conduct audits for compliance with the documentation three times a week if incident reports are available for two weeks, then weekly for six weeks, then monthly for four months.
On-the-spot education will be provided to staff as needed. The results of these logs/audits along with a Root Cause Analysis of any identified issues will be brought to the Quality Assurance and Performance Improvement Committee for two quarters for further analysis and corrective action as needed. The committee will determine the need for additional audits or reporting.
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