§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 observation, resident and staff interviews, policy review, and clinical record review, it was determined that the facility failed to document completely and accurately on the clinical records for one of three residents reviewed (Resident 1).
Findings include:
A review of the facility policy, titled "Charting and Documentation", last revised July 2017, revealed the medical record should facilitate communication between the interdisciplinary team.
Review of the clinical record for Resident 1 on July 29, 2024, revealed diagnoses that included congestive obstructive pulmonary disease (COPD-disease process that causes decreased ability of the lungs to perform) and anemia (a reduction in red blood cells).
Observation of Resident 1 on July 29, 2024, at 1:00 PM, revealed the Resident resting in his bed. The Resident had no complaints regarding his care and services.
On July 17, 2024, Resident 1 left the facility on a leave of absence (LOA). Resident's family member signed Resident 1 out in the sign out log at the main desk, but entered the wrong date. Resident 1's niece confirmed the date of LOA was July 17, 2024, at 12:00 PM, and not July 16, 2024.
During an interview with Resident 1, he was asked if he recalls taking a LOA from the facility recently. Resident 1 informed the surveyor that he took a leave of absence on July 17, 2024, and returned July 19, 2024. Resident 1 was asked if he told anyone he was taking a LOA on July 17, 2024, Resident 1 informed the surveyor that he informed the medication nurse, Employee 1 (Licensed Practical Nurse), when she was giving his medications on July 17, 2024. Resident 1 was asked if he informed Employee 1 that he was taking a LOA for more than a day, and he replied "no," and added that he wasn't aware that it was necessary since he is approved for LOA.
During an interview with Employee 1 on July 29, 2024, Employee 1 admitted that she forgot to document Resident 1's LOA on July 17, 2024. Employee 1 also confirmed that she documented a late entry for the LOA on July 18, 2024, at 2:30 AM, when she was asked about any knowledge of Resident 1's LOA.
During an interview with the Nursing Home Administrator (NHA) on July 29, 2024, at approximately 2:30 PM, the NHA confirmed that documentation should include a Resident's LOA and the expected date and time of the resident's return.
28 Pa. Code 211.12(d)(1)
| | Plan of Correction - To be completed: 08/20/2024
Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.
F842
1. Resident # 1 was on an approved LOA.
2. An audit will be completed of any resident who went on LOA in the last 2 weeks to ensure documentation was completed.
3. DNS or designee will provide re-education to licensed nursing staff and receptionist that residents may go LOA with physician orders, documentation needs to be completed at time of leaving facility and when resident returns from LOA. During morning clinical meeting and stand down meeting, residents that are or went out on LOA to ensure documentation is in the medical record.
4. DNS or designee will complete random audits of residents who go LOA weekly for 4 weeks and then monthly for 2 months to ensure documentation is completed when leaving and returning to facility. Audit findings will be reported to the monthly QAA for review and recommendations.
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