§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 review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that clinical records were accurately documented for two of 32 residents reviewed (Residents 42, 70).
Findings include:
A significant change comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 42, dated July 29, 2019, revealed that the resident had moderately impaired cognition, had diagnoses that included diabetes (disease that interferes with blood sugar control), and received daily insulin (medication that lowers blood sugar levels). Physician's orders dated July 25, 2019, included orders for the resident to receive 18 units of Novolog (fast-acting) insulin if the resident ate 50 to 74 percent of the meal, and 34 units if the resident ate 75 to 100 percent of the meal. Orders on August 2, 2019, were for the resident to receive 12 units of Novolog (fast-acting) insulin if the the resident ate 50 to 74 percent of the meal, and 25 units if the resident ate 75 to 100 percent of the meal.
Resident 42's meal percentage records and Medication Administration Records (MAR's) for July and August 2019 revealed that the resident ate 50 to 74 percent, or 75 to 100 percent of the breakfast meal on July 26, 27 and 30, and August 1, 2, 3, 4, 6, 7, 8, 10 and 12; the lunch meal on July 30 and August 1, 4, 6, 8 10, 11 and 12; and the supper meal on July 29 and 30, and August 2, 3, 5, 6, 7, 8, 9, 10 and 11, 2019. However there was no documented evidence regarding how many units of insulin were administered to the resident based on the percentage of meal consumed.
Interview with Registered Nurse Assessment Coordinator 7 on September 11, 2019, at 1:43 p.m. confirmed that the amount of insulin that was administered based on Resident 42's percentage of the meal consumed was not documented.
The facility's policy regarding wound care, dated April 10, 2019, indicated that after completing a wound dressing, staff were to complete the appropriate documentation in the resident's electronic medical record.
A diagnosis record for Resident 70, dated April 8, 2019, revealed that the resident had diagnoses that included peripheral vascular disease (disease or disorder of the circulatory system outside of the brain and heart.). A wound note dated August 20, 2019, indicated that the resident had vascular arterial ulcerations (a sore caused by poor circulation) of the first, second, third and fifth toes of the right foot and also the right heel. Physician's orders, dated August 27, 2019, included an order for the first, second, third and fifth toes of the right foot to be treated by applying betadine, covering with a non-adherent dressing, wrapping with Kerlix (gauze wrap), and changing the dressing daily every day shift and as needed for dislodgement/soilage
Observations of Resident 70 on September 9, 2019, at 1:52 p.m. revealed that the resident was sitting in her wheelchair in her room. She had a dressing to that right foot that had a 3-inch area of red-colored drainage on it in the area of the small toe, the side of the foot, and the area under the toes.
Interview with Licensed Practical Nurse 10 on September 9, 2019, at 4:00 p.m. revealed that bloody draining seeps through Resident 70's right foot dressing at times, and the resident bumps it a lot.
As of September 10, 2019, there was no documented evidence that any "as needed" dressing changes due to drainage and/or bleeding were completed for Resident 70's right foot dressing since September 7, 2019, and there was no other documented evidence of bleeding at the wound site that required dressing changes for the month of September 2019.
Interview with Registered Nurse 4 on September 10, 2019, at 5:18 p.m. revealed that she assisted with an "as needed" dressing change for Resident 70's right foot during the evening shift on September 9, 2019, but there was no documentation regarding this dressing change on the resident's clinical record. She also indicated that the nurse who worked on September 8, 2019, indicated that the dressing was changed due to drainage that day, but this was not documented.
Interview with the Director of Nursing on September 11, 2019, at 10:36 a.m. confirmed that there was no documentation on Resident 70's clinical record, including on the Treatment Administration Record (TAR) regarding the "as needed" dressing changes that were completed, and nurses were to document on the TAR when the dressing was changed.
28 Pa. Code 211.5(f) Clinical Records.
28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 8/16/18.
| | Plan of Correction - To be completed: 11/04/2019
There is no evidence that Resident R42 had any adverse effects from improper documentation.
Staff interviewed stated they administer the proper amount of insulin according to the meal percentage, however, they admit to not documenting according to policy.
There is no evidence that R70 was negatively affected by the findings of inaccurate documentation. Upon review, R70's wound had shown improvement.
Staff interviewed regarding the lack of documentation revealed the Infection Prevention Nurse was assisting the Licensed Practical Nurse with the dressing change. Both failed to document on the day of the dressing change. A late entry was submitted.
The Clinical Educator or designee will provide education to licensed nurses as to the procedure for complete and accurate documentation in the Electronic Medical Record specific to administering insulin in accordance with resident meal consumption. This education will also be provided for newly hired licensed staff members, as well as, for any licensed agency staff during their orientation.
The Director of Nursing or designee will complete a random audit monthly for 3 months on proper documentation of insulin administration based on meal percentage.
The Director of Nursing or designee will provide education to licensed nurses as to the procedure for Wound Dressing documentation as per facility policy.
The Director of Nursing or designee will complete a chart review of current residents whom have wounds to ensure documentation is compliant.
The Director of Nursing or designee will complete a random audit monthly for 3 months to determine compliance of proper documentation of wound dressings according to facility policy.
Results of the audits will be reported and trended to the facility's Quality Assurance Steering Committee. The Quality Assurance Steering Committee will determine the frequency of the audits after the initial three months are completed.
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