|§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 four of 36 residents reviewed (Residents 12, 13, 49, 269).
The facility's policy regarding documentation, dated October 24, 2019, revealed that all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, were to be documented in the resident's medical record. The medical record was to facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.
A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 12, dated November 30, 2019, indicated that the resident was alert and oriented, and had diagnoses that included diabetes. Physician's orders, dated February 15, 2017, included orders for staff to check the resident's blood sugar four times a day, and insulin was to be administered depending on the results of the blood sugar tests.
Resident 12's blood sugar test results for June 2019 revealed that staff documented that the 9:00 p.m. blood sugar on June 24, 2019, was 1,390 milligrams per deciliter (mg/dL). However, there were no corresponding nursing notes that addressed the extremely high blood sugar result and no indication that the resident's physician was notified.
Interview with the Director of Nursing on December 19, 2019, at 4:05 p.m. confirmed that there was no other documentation that supported the June 24, 2019, at 9:00 p.m. blood sugar of 1,390 mg/dL, including the administration of insulin, a registered nurse assessment, and physician notification. The Director of Nursing indicated that the blood sugar entry of 1,390 had to be an error.
A diagnosis record for Resident 13, dated December 1, 2019, revealed that the resident had diagnoses that included dementia with dysphagia (difficulty swallowing) and required a Percutaneous endoscopic gastrostomy (PEG) tube (a tube surgically inserted into the stomach to provide feeding). Physician's orders for Resident 13, dated January 21, 2019, included an order for the resident to receive Jevity 1.5 at 60 mililiters (ml) an hour for 20 hours per day to provide a total of 1300 ml/day, and an order, dated July 18, 2019, for the resident to receive PEG tube flush of 200 ml water every four hours.
Resident 13's current care plan, revised October 1, 2019, revealed that the resident was to be provided enteral feeding and flushes per the physician orders and to check tube placement and residuals per guideline or physician orders.
Resident 13's clinical record for January 1 through December 18, 2019, revealed that there was no documented evidence that gastric residuals were checked every six to eight hours per the facility's policy, and the total volume of feeding formula and flushes received by the resident each day was not calculated and recorded.
Interview with Licensed Practical Nurse 1 on December 17, 2019, at 10:27 a.m. revealed that he was not aware of any way to calculate the total amount of fluid Resident 13 actually received each shift, and he was not sure if the feeding tube pump was able to give an accurate amount of fluids that the resident received.
Interview with the Dietician on December 19, 2019, at 3:06 p.m. revealed that she was not aware that nursing staff were not keeping an accurate account of Resident 13's intake. She indicated that she used the amount of fluids the resident was ordered to receive and not the actual amount the resident received when determining intake; therefore, she did not have an accurate account of the fluids the resident received.
A diagnosis record for Resident 49, dated December 1, 2019, and nursing note dated November 19, 2019, at 6:23 p.m., revealed that the resident had diagnoses that included a brain injury with dysphagia and required a PEG tube. Physician's orders, dated December 12, 2019, included an order for the resident to receive Glucerna 1.2 at 80 ml an hour, to be connected at 8:00 p.m. and disconnected at 6:00 a.m. A nutrtition note, dated December 12, 2019, revealed that the tube feeding would provide 960 calories, 48 grams of protein, and 1364 cubic centimeters (cc's) of free fluid per day.
Resident 49's clinical record for December 12-18, 2019, revealed no documented evidence that the amount of tube feeding formula received during the time the feeding was connected was recorded.
Interview with the Nursing Home Administrator on December 20, 2019, at 2:32 p.m. confirmed that there was no documented evidence that the amount of tube feeding formula that Resident 49 received was recorded in the resident's clinical record.
An admission nursing note for Resident 269, dated December 16, 2019, indicated that the resident was oriented to person and place, his skin color was normal, his nail beds were normal in appearance with brisk capillary refill, his lips and mucus membranes were pink in color, his lung sounds were diminished throughout all fields, and oxygen was ordered as needed.
Observations of Resident 269 on December 17, 2019, at 11:22 a.m. revealed that the resident was in a wheelchair in his room, and his nail beds were dark purple and his hands were cool. The surveyor asked Licensed Practical Nurse 1 to check the resident, and the nurse obtained oxygen saturation levels (the percentage of oxygen in the blood) of 73 percent and 65 percent (normal is 90-100 percent). Licensed Practical Nurse 1 placed the resident on oxygen at a flow rate of 2 liters per minute via nasal cannula (tubes placed in the nostrils). A recheck of Resident 269's oxygen saturation on December 17, 2019, at 11:42 a.m. revealed that the resident's readings were still low at 45 percent. Licensed Practical Nurse 1 stated that it was because the resident's hands were cold and that he would try to warm his hands to get a better reading. The pulse oximeter (machine that reads the oxygen level) was reading a correct pulse as confirmed by a manual pulse. The surveyor asked Licensed Practical Nurse 1 what he would do in this case, and he responded that he would put the resident on oxygen and recheck him. The nurse indicated that the resident was not having any issues. The surveyor asked the nurse if he would do anything else, and he responded, "Not at this time, no."
As of December 18, 2019, at 9:52 a.m. there was no documentation in Resident 269's clinical record regarding the hypoxic (low oxygen) episode on December 17, 2019.
An interview with Licensed Practical Nurse 1 on December 18, 2019, at 10:51 a.m. confirmed that he did not document that Resident 269 had a hypoxic episode on December 17, 2019, and he did not notify the registered nurse and/or the physician about the change in the resident's condition.
An interview with the Director of Nursing on December 18, 2019, at 11:00 a.m. confirmed that there was no documented evidence that Licensed Practical Nurse 1 or a registered nurse documented Resident 269's hypoxic episode on December 17, 2019.
28 Pa. Code 211.5(f) Clinical Records.
Previously cited 12/13/18.
| ||Plan of Correction - To be completed: 02/12/2020|
R12 blood sugar results have been recorded and the physician was notified when the results have been outside the normal limits of the sliding scale coverage. The results of those blood sugars are also shared with the resident at the time of testing.
R13 clinical record now reflects that gastric residuals are checked every six to eight hours per the facility's policy and the total volume of the feeding formula and flushes received are calculated and recorded on the Medication Administration Record.
R49 clinical record now reflects the amount of tube feeding formula that would be provided to the resident. This amount will be recorded on the Medication Administration Record.
The dietician has been made aware of the changes to ensure accuracy of consumption.
R269 Registered Nurse assessment following the hypoxic episode was recorded in the clinical chart. The physician for R269 was also notified of the hypoxic episode.
The listing of all residents who receive tube feeding formula was audited to ensure consumption is measured and recorded in the clinical chart. Results will be reported to the Quality Assurance committee quarterly. The Administrator will be responsible for any follow up recommendations by the Quality Assurance committee.
The director of nursing/designee will educate the licensed staff that all residents who receive tube feeding formula must have the consumption recorded on the clinical chart to ensure resident records reflect identifiable information. This education will be provided to new and agency licensed staff. A weekly audit will be conducted by the Assistant Director of Nursing or Designee to ensure those residents have their consumption recorded on the clinical record for four weeks.
Results will be reported to the Quality Assurance committee quarterly. The Administrator will be responsible for any follow up recommendations by the Quality Assurance committee.