§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 clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for three of five residents reviewed (Residents 1, 2, 5).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated April 30, 2024, revealed that the resident was cognitively intact, was dependent on staff for personal hygiene care, and had diagnoses that included dementia.
Review of nurse aide documentation for Resident 1, dated March and April, 2024, revealed that care provided by a nurse aide was not documented by the dayshift nurse aide on March 4, 9, 27, and April 15, 16, 18, 20, 22, 24, 2024.
A quarterly MDS assessment for Resident 2, dated May 24, 2024, revealed that the resident was cognitively intact, required substantial to maximum assist for personal hygiene care, and had diagnoses that included Multiple Sclerosis.
Review of nurse aide documentation for Resident 2, dated March, April, and May 2024, revealed that care provided by a nurse aide was not documented by the dayshift nurse aide on March 4, 5, 14, 20, 31; April 11, 24, 28, 29; or May 3, 25, 2024.
A quarterly MDS assessment for Resident 5, dated April 22, 2024, revealed that the resident was severely cognitively impaired, was dependent on staff for all personal care needs, and had diagnoses that included dementia.
Review of nurse aide documentation for Resident 5, dated March, April, and May 2024, revealed that care provided by a nurse aide was not documented by the dayshift nurse aide on March 4, 5, 10, 27, and 29, 2024, or by the evening shift nurse aide on March 11, 2024. Care provided by a nurse aide was not documented by the dayshift nurse aide on April 16, 18, 25, 28, and 29, or by the evening shift nurse aide on April 22, 2024; and care provided by a nurse aide was not documented by the dayshift nurse aide on May 12 and 17, 2024, or on the evening shift on May 13, 19, and 25, 2024.
An interview with the Assistant Director of Nursing on May 29, 2024, at 2:09 p.m. confirmed that documentation of care provided by nurse aides was not complete and accurate for Residents 1, 2, and 5 on the above-mentioned dates and shifts.
28 Pa Code 211.5(h) Clinical Records.
28 Pa. Code 211.12(d)(5) Nursing Services.
| | Plan of Correction - To be completed: 06/28/2024
1. Point of Care charting was reviewed at the time the issue was brought to the facility's attention. Resident's 1, 2, and 5 were noted to not have charting for different shifts for all dates in question. There were no ill effects to Resident's 1, 2, or 5 as a result of this.
2. Daily staffing assignments were pulled for each individual date and individual education was provided for each staff member who failed to document for the dates in question for residents 1, 3, and 5.
3. Education was provided to all certified nurse's aides regarding accurate and complete documentation being completed prior to leaving at the end of each shift. Education was also provided to licensed staff on their responsibility to ensure that documentation is complete prior to aides leaving at the end of each shift.
4. Director of Nursing/Designee will audit charting completion for five random residents/unit on each shift weekly for four weeks and then monthly for an additional two months. Results will be reviewed at quarterly Quality Assurance Meetings.
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