§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 and staff interview, it was determined that the facility failed to maintain accurate and complete clinical records, according to professional standards of practice for one of six sampled residents (Resident 1).
Findings include:
According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient record to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care: Assessments, Clinical problems, Communications with other health care professionals regarding the patient, Communication with and education of the patient, family, and the patient's designated support person and other third parties.
According to the Title 49, Professional and Vocational Standards, Department of State, Chapter 21 State Board of Nursing Subsection 21.11 (a) The register nurse assesses human responses and plans, implements and evaluates nursing care for individuals or families for whom the nurse is responsible. In carrying out this responsibility, the nurse performs all of following functions: (4) Carries out nursing care actions which promote, maintain, and restore the well-being of individuals (6)(b) The registered nurse is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care delivered and Subsection 21.18. (a)(5) document and maintain accurate records.
According to the Title 49, Professional and Vocational Standards, Department of State, Chapter 21 State Board of Nursing Subsection 21.145. (a) The licensed practical nurse (LPN) is prepared to function as a member of a health-care team by exercising sound nursing judgement based on preparation, knowledge, skills, understanding and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place.
Clinical record review revealed that Resident 1 was admitted to the facility on March 17, 1997, with diagnoses to include incomplete quadriplegia (severe or complete loss of motor function in all four limbs) and neurogenic bowel (loss of bowel control due to brain or spinal cord damage).
An interview with Resident 1 on May 29, 2024, at approximately 12:30 PM revealed the resident was upset about an incident during which staff put him on the bedpan after they gave him his bowel protocol and forgot he was on it. The resident stated he was on the bed pan most of the night and when the staff finally took him off, he had a pressure sore on his butt. The resident stated that over the last weekend the facility ran out of the Mesalt (a dressing that helps manage wounds) that is used to treat his wound and he did not receive his wound treatment as prescribed.
A review of a physician's order dated May 17, 2024, revealed the following treatment, Collagenase Ointment 250 UNIT/GM apply to right and left ischial wounds topically every dayshift. Cleanse with normal saline, pat dry, apply Santyl (nickel thickness) over slough within wound base, and unfold Mesalt sheet and fluff into wound bed and cover with 4x4 secure with ABD pad minimal tape change daily.
An interview with Employee 4 LPN on May 29, 2024, at 2:20 PM revealed the employee stated she had provided the resident's precribed wound treatment as ordered for dayshift on May 26, 2024, and used the last of the Mesalt at that time. Employee 4 stated that she had to perform another dressing change for the resident later in the day on May 26, 2024, because the dressing was soiled. The employee indicated she tried to call the on call physician twice about the Mesalt not being available, but the physician never called the facility back.
A review of the resident's clinical record revealed Employee 4 failed to document in the clinical record that there wa no Mesalt available to complete the resident's wound treatment. There was also no documented evidence that Employee 4 attempted to call the resident's physician on two occasions on May 26, 2024, as stated in her interview.
Employee 4 failed to document in the resident's treatment record that she changed the resident's wound dressing later in the day on May 26, 2024, due to the dressing becoming soiled.
A review of Resident 1's May 2024 Treatment Administration Record revealed that on May 27, 2024 Employee 6 LPN signed the record indicating that she performed the treatment as prescribed despite the unavailability of the Mesalt to complete the treatment as ordered. Employee 6 did not document and consultation with the physician regarding any interim treatment desired due to the unavailability of the Mesalt
A review of a facility's investigation dated February 4, 2024, revealed at 4:30 AM staff found Resident 1 lying on the bedpan. Employee 1 LPN (license practical nurse) signed in the clinical record that Resident 1 was placed on the bedpan at 9:27 PM on February 3, 2024, and taken off the bedpan at 9:36 PM on February 3, 2024. The facility's report indicated that Employee 1 falsely documented that staff took Resident 1 off the bedpan on February 3, 2024, at 9:36 PM.
An interview with the Nursing Home Administrator on February 6, 2024, at approximately 3:00 PM confirmed that the facility's nursing staff failed to accurately document in the resident's clinical record.
28 Pa. Code 211.5 (f)(iii) Medical records.
28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services.
| | Plan of Correction - To be completed: 07/15/2024
Preparation and submission of this
Plan of Correction does not
constitute admission for purposes of
general liability, professional
malpractice or any other court
proceedings.
F 0842 Level D Medical Record (Falsification of Documentation)
1. Contain elements detailing how the facility will correct the deficiency as it relates to the individual;
Resident 1 refused assessment of his wound by facility treatment team, seen at the St. Luke's wound clinic 5/31/2024 to assess his wound.
Employee's 4 and 6 will receive a discipline for failing to follow the proper process for documentation/false documentation. To be completed by 7/15/2024.
Employee 1 was an agency employee who has been tagged as Do Not Return to Pleasant Valley Manor and reported to the State Board of Nursing due to actual harm resulting from her false documentation.
2. Indicate how the facility will act to protect residents in similar situations
Staff re-education on what to do if a treatment/medication is not available. Importance of accurate documentation of what is done/not done for each resident. To be completed by 7/15/2024.
3. Include the measures the facility will take or the systems it will alter to ensure that the problem does not recur;
Random Audits of dates/initials on wound dressings to check if documentation of treatments is accurate. Weekly x 4 weeks and then monthly to monitor compliance. To be instituted by 7/15/2024.
4. Indicate how it plans to monitor its performance to make sure that solutions are sustained
Audits will be reviewed at QAPI to assess need for revision, increased education, and/or continuation
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