§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 facility policy and clinical records, and staff interview, it was determined that the facility failed to have complete and accurate documentation regarding wound dressing changes for one of three residents reviewed with wounds in the treatment record (Resident R1).
Findings include:
Review of facility policy entitled "Documentation," dated 2/14/24, indicated, "Treatments done will be charted in the Electronic Treatment Administration Record (ETAR) ...Document information as soon as possible to ensure accuracy of the information and to reflect ongoing care."
Review of facility policy entitled "Dressing change Protocol," dated 2/14/24, indicated, "Initial completion on Treatment Administration Record."
Review of Resident R1's clinical record revealed an admission date of 10/13/22, with diagnoses that included pain, weakness, seizures, and chronic kidney disease. The clinical record revealed that on 2/20/24, R1's physician ordered a wound dressing change to be completed daily and as needed.
Resident R1's ETAR for February 2024, revealed five days (2/21/24, 2/22/24, 2/23/24, 2/24/24, and 2/25/24) that lacked documentation indicating the wound dressing change was completed per physician orders.
During an interview on 3/07/24, at 3:22 p.m. the Director of Nursing confirmed that Resident R1's treatment records did not have complete documentation regarding wound dressing changes.
28 Pa. Code 211.5(f)(xiii)(ix) Medical Records
28 Pa. Code 211.12(d)(1)(5) Nursing Services
| | Plan of Correction - To be completed: 04/19/2024
- Wound condition and measurements for resident R1 did not worsen evidenced by comparison of assessments of wound recorded on 2/6/24 to 2/27/24.
- Records of other residents with orders for treatments were reviewed for accuracy. No one was identified as having a negative outcome.
- All LPNs and RNs will be educated of the requirement to follow MD orders.
- DON or designee will run a Treatment Administration Record (TAR) audit report, daily x1 month, 3x/week x2 weeks and weekly x2 weeks to monitor appropriate documentation of treatments following up with 1:1 education for those not maintaining compliance.
- To ensure the deficient practice will not recur, nurses' working11-7 shift will integrate running TAR administration audit for the last 24 hours, for their given assignment. DON or designee monthly will review audits and a summary reviewed at Quality Assurance Process Improvement meetings.
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