|§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 clinical record reviews and staff interviews, it was determined that the facility failed to maintain clinical records that were accurately documented for one of 39 residents reviewed (Resident 110).
A nursing note, dated March 5, 2020, at 11:45 p.m. revealed that Resident 110 had audible wheezing; decreased breath sounds; a harsh, congested non-productive cough; a temperature of 101.8 degrees Fahrenheit; and his color was pale. On March 6, 2020, at 12:15 a.m. the physician was notified and orders were received for a chest x-ray, a flu swab (test for influenza), and nebulizer treatments.
A laboratory report, dated March 6, 2020, revealed that the resident tested positive for influenza A virus, the physician was notified, and droplet precautions (special infection control procedures) were ordered.
However, there was no documented evidence that the physcian's order to implement droplet precautions was entered into Resident 110's electronic medical record until March 9, 2020.
Interview with the Director of Nursing on March 11, 2020, at 4:03 p.m. confirmed that staff did not enter the physician's order for droplet precautions into the electronic medical record until March 9, 2020.
28 Pa. Code 211.5(f) Clinical records.
| ||Plan of Correction - To be completed: 04/03/2020|
1. Resident 110 had no ill effects from the physician order for droplet precautions not being documented in the electronic record timely.
2. Current residents' orders for droplet precautions will be audited for the last 5 days to ensure that the physician's order was entered into the electronic record timely.
3. Licensed nursing staff will be educated on entering droplet precautions into the electronic medical record timely. New licensed staff will be educated on this during orientation. If or when agency staff is utilized they will be educated on this prior to working in the facility.
4. An audit of five residents will be completed weekly for four weeks and the monthly for two months to ensure that residents with physician's orders for droplet precautions are entered into the electronic medical record timely. Audit results will be reviewed by the Quality Assurance Process Improvement Committee.