|§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-
(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 a review of select facility policy and clinical records and staff interviews, it was determined that the facility failed to maintain accurate and complete clinical records, according to professional standards of practice, by failing to accurately document care and services provided to one resident of five sampled ( Resident CR1).
According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient record to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care: Assessments, Clinical problems, Communications with other health care professionals regarding the patient, Communications with and education of the patient, family, and the patient's designated support person and other third parties.
Review of facility policy provided at the time of the survey ending June 14, 202, entitled: "Emergency Response Guidelines", indicated that it is the policy of the facility that guidelines are to be utilized in the event of a resident emergency. Step 7 of the guidelines indicated that staff are to "Chart completely all events leading up to the situation, what transpired during the situation, and the events that followed. All of this information along with the date, time and the nurse's signature should be documented in the narrative nurse's notes."
Review of facility policy provided at the time of the survey ending June 14, 2022, entitled:" CPR Policy & Procedure", revealed that the purpose of the procedure is to provide guidelines for the initiation of Cardiopulmonary Resuscitation (CPR)/Basic Life Support (BLS) in victims of sudden cardiac arrest. The policy indicates document the following in the resident's medical record (if the victim is a resident).
"The condition in which the resident was found in or the witnessed event
"The sequence of resuscitation efforts, including approximate times.
"The victims response
"The approximate time that EMS team took over
"Time of death or time the individual was transported.
Review of Resident CR1's clinical record revealed a progress note written by Employee 3, RN, dated May 31, 2022, at 0316 (3:16 AM) revealed, "Patient was observed by CNA upon making rounds to be unresponsive at 2:40 AM CPR initiated, 911 called arrived at 2:50 AM epinephrine, narcon (Narcan, spelled wrong in record) was administered. At 3:05 AM patient was pronounced by, (physician's name). Pt's brother called no answer."
Interview with the Nursing Home Administrator and Director of Nursing on June 14, 2022, at approximately 11:00 AM revealed he was unable to state which staff members had provided CPR to Resident CR1 or if the AED was utilized as there was limited information in the clinical record. However the NHA stated that he was informed that new AED pads needed to be ordered.
The DON stated during interview on June 14, 2022, that facility would not document employee names in the resident's clinical record. However, the clinical record documentation did not identify individuals by title (RN, LPN, nurse aide) or any other means to accurately record sequence of events surrounding the staff's resuscitation efforts and staff's emergency response. The DON was was also unaware of the staff members who had provided CPR to Resident CR1.
Following surveyor inquiry and a review of Ambulance documentation (received via fax by the facility time stamped during the survey at June 14, 2022 at 10:04 AM) revealed that on May 31, 2022, at 2:48 AM the EMS noted that "CPR and AED performed by other." The EMS documentation noted that "AED on PT by staff, no shock advised, CPR in progress successful. Pt response: unchanged Oxygen initiated at 25 lpm. Bag valve Mask performed by other. BVM ventilations being given by staff." EMS documentation revealed that EMS took over at 2:49 AM.
Interview with the Director of Nursing on June 14, 2022 at approximately 2:00 PM confirmed Employee 3, RN failed to follow the facility's policy and procedures for emergency response and CPR documentation in the resident's clinical record.
Refer to F 678
28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing Services
28 Pa. Code 211.5 (f)(g)(h) Clinical Records
| ||Plan of Correction - To be completed: 07/12/2022|
1. A copy of the ambulance company's clinical record documentation labeling AED placement and correct CPR technique will be scanned into the resident's chart.
2. The nursing notes placed in our clinical record will be reviewed on a daily basis in morning meeting and addendums will be made for completeness and accuracy if necessary. Notes will be checked for completeness and accuracy.
3. Nursing staff will be educated on the importance of writing detailed and timely notes. We will define the parameters that we expect to have covered in a note and they will sign off on our clinical documentation policy.
4. An audit will be conducted on the daily reviewed notes. The audit will be conducted by the DON or designee weekly x 5 and monthly x2. Results of this audit will be submitted and discussed in QA.