|§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 review of policies and clinical records, 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 five residents reviewed (Resident 2).
The facility's policy regarding medication administration, dated August 19, 2019, revealed that the facility had flexible times for the administration of daily medications, but that due to computerization, a specified administration time would be entered on the Medication Administration Record (MAR) (such as 9:01 a.m. for morning medications).
A nursing note, dated July 8, 2019, at 8:30 p.m. revealed that Resident 2 was sent to a surgical center to have surgery and the resident's family member notified the facility that the surgical center did not complete the surgery and they were sending the resident to the emergency room for evaluation of stroke-like symptoms. The resident's family member called and informed the facility that they decided not to send the resident to the emergency room due to becoming increasingly agitated and aggressive and requesting to return home. The resident returned to the facility, was noted to be her usual self, was alert with clear speech, and was able to be understood.
A physician's progress note for Resident 2, dated July 8, 2019, indicated that the resident was seen for an episode of troubled speech that occurred the prior day, and on the day of examination she had some increased confusion. The diagnoses included aphasia (trouble understanding, speaking, reading, or writing) following unspecified cerebrovascular disease and the plan was to treat her with aspirin. A physician's order, dated July 9, 2019, included an order for the resident to receive 81 milligrams (mg) of enteric coated (delayed release) aspirin every morning.
Resident 2's Medication Administration Record (MAR) for July 2019 revealed that aspirin was scheduled to be administered on July 9, 2019, at 9:01 a.m., and the aspirin was signed by staff as being administered. A medication administration log report indicated that the aspirin was administered at 12:57 p.m.; however, a nursing note dated July 9, 2019, at 12:45 p.m. indicated that the resident refused the aspirin. There was no documented evidence on the MAR that the resident refused the aspirin.
Interview with the Assistant Director of Nursing on September 9, 2019, at 9:33 p.m. revealed that Resident 2 refused aspirin at 12:45 p.m. on July 9, 2019; however the nurse re-approached the resident at 2:30 p.m. and the resident took the aspirin. He confirmed that there was no documentation on the resident's MAR that the resident refused the aspirin at 12:45 p.m., and no documented evidence that aspirin was administered at 2:30 p.m.
28 Pa. Code 211.5(f) Clinical records.
28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 8/22/19.
| ||Plan of Correction - To be completed: 10/01/2019|
1. Resident 2 did not suffer any ill effects from the medication not being documented as refused at the time of refusal and not documented as administered at the time that it was administered.
2.Observation of licensed nurses and/or verbal statements of proper procedure for documenting administration and refusal at the time of action was completed
3.Education was completed for licensed nurses regarding documentation of administration and refusal of medications at the time of action.
4.Audits of proper documentation of refusal and administration of medications for 5 nurses will be completed every week x 4 weeks and every month x 2. Identified trends will be investigated. Results will be reported to the Quality Assurance committee.
Yes, new licensed staff will be educated on this issue as part of the new hire orientation process.