§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 maintain clinical records that were accurately documented for one of three residents reviewed (Resident 1).
Findings include:
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated December 27, 2023, revealed that the resident was understood, understands, and had a diagnosis which included osteomyelitis (a serious infection of the bone that can be either acute or chronic) and aquired absence of the right great toe.
A wound healing center note for Resident 1, dated January 2, 2024, revealed that staff was to leave the dressing on the resident's foot for three days and then apply betadine dressings daily.
Review of Resident 1's Treatment Administration Record (TARs) for January 2024 revealed that staff completed the betadine dressing to the resident's right foot on January 5, 2024. However, there was no documented evidence that the betadine dressing was completed on January 6 and 7, 2024, as per the wound healing center's recommendations.
Interview with the Director of Nursing on January 26, 2024, at 12:00 p.m. confirmed that there was no documented evidence that the betadine dressing was completed as per the wound healing center's recommendations on January 6 and 7, 2024.
Interview with Registered Nurse 1 on Janaury 26, 2024, at 1:30 p.m. revealed that she completed the betadine dressing to Resident 1's right foot on January 6 and 7, 2024. She indicated that she recalls that the resident was always noncompliant and standing on that foot and that the dressing was off his foot on the 6th, so she went in and completed the treatment. She indicated that she also completed the treatment on the 7th as well.
28 Pa. Code 211.5(f) Clinical records.
28 Pa. Code 211.12(d)(3)(5) Nursing services.
| | Plan of Correction - To be completed: 03/04/2024
Resident 1 no longer resides in the facility.
Any resident who receives physician treatment orders for dressings and/or dressing changes has the ability to be affected by this alleged deficient practice.
A whole house audit on residents with treatment orders for dressings/dressing changes was completed to ensure documentation of dressing completion and/or dressing change was completed and present in the medical record.
Licensed Nursing Staff , including Agency Licensed Staff, re-educated on the importance of documenting dressing completion and/or dressing change as per physician orders in the medical record.
The Director of Nursing/designee will audit treatment administration records for residents who are to receive dressings/dressing changes weekly times eight weeks and then monthly times three months and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement and/or continuation of audits.
Results of these audits will be reviewed in Quality Assurance and Performance Improvement times three months or until substantial compliance is noted.
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