|§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.
document the administration of a medications and treatments ordered by the physician for 15 of 24 resident records reviewed (Resident R1, R2, R4, R5, R7, R9, R10, R11, R12, R13, R15, R16, R17, R18 and R19).
Review of the Electronic Medication Administration Record (EMAR) on November 8, 2021 during the 3 p.m. to 11:00 p.m. shift for Resident R1, R2, R4, R5, R7, R9, R10, R11, R12, R13, R15, R16, R17, R18 and R19 revealed that medications were not documented as administered by Registered Nurse (RN) Employee E15.
Facility documentation revealed a letter dated November 20, 2021 signed by the RN stating that on November 8, 2021 during the 3-11 shift, "All meds and care were completed and given."
The Director of Nursing on November 20, 2021 at 3:00 p.m. confirmed the RN administered the medications as ordered but failed to document that they were administered.
28 Pa. Code 211.5(f) Clinical records
28 Pa. Code 211.12(d)(1) Nursing services
28 Pa. 211.12(d)(5) Nursing services
| ||Plan of Correction - To be completed: 12/27/2021|
1. Statement obtained by Employee # 15 that she did administer the ordered medications including controlled substances which were signed for.
2. Capable residents were interviewed on unit 2C. All denied any concerns related to not receiving medications.
3. Licensed Nurses will be educated by the Director of Nursing / designee on medication administration including documentation of medication administered.
4. Audits of medication administration documentation will be completed by the Director of Nursing / designee at the clinical meeting to ensure completion. The audits will be conducted weekly for 4 weeks and then monthly for 2 months. Findings of the audits will be submitted to the monthly QAPI committee for review.
5. DOC 12/27/2021