|§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 facility policies, clinical record review and interviews with residents and staff, it was determined that the failed to maintain complete and accurate clinical records related to colostomy care for one of three residents reviewed (Resident R1).
Review of facility policy, "Colostomy (a surgical procedure that brings one end of the large intestine out through an opening (stoma) made in the abdominal wall) /Ileostomy Care" dated revised February 2019, revealed that "The following information should be recorded in the resident' s medical record: The date and time the colostomy/ileostomy care was provided, the name and title of the individual(s) who provided the colostomy/ileostomy care, any breaks in the resident' s skin ... how the resident tolerated the procedure ... the signature and title of the person recording the data."
Interview on November 20, 2019, at 9:10 a.m., Resident R1 stated that she sometimes has to wait too long for assistance to go to the bathroom and that staff only empty her colostomy when she asks. The resident further indicated that staff do not empty her colostomy every shift, that it gets full frequently, leaks, comes off, spills stool on her and that she needs assistance with emptying it.
Review of Resident R1' s Medication Administration Records (MARs) for November 2019 revealed a physician' s order dated October 30, 2019, for "Colostomy care every shift and as needed." Continued review of the MARs revealed that no colostomy care was recorded as provided on seven shifts; specifically, that no care was documented on November 1, 5, 6 and 19 on the day shift, November 7 on the evening shift and November 2 and 14 on the night shift.
Review of Resident R1' s progress notes revealed that no notes were available on the above dates to indicate if colostomy care was provided.
Review of nurse aide documentation related to bowel management revealed that no bowel management information was recorded on 16 shifts; specifically that no information was recorded for any shift on November 1, and that no information was recorded on November 2, 5, 6, and 18 on the day shift, November 5, 11, 13 and 17 on the evening shift and November 2, 3, 6, 7 and 18 on the night shift.
Interview on November 20, 2019, at 1:20 p.m. the Director of Nursing (DON) confirmed that Resident R1' s colostomy care was not documented on the above dates.
The failed to maintain complete and accurate clinical records related to colostomy care.
28 Pa Code 211.5(f) Clinical records
Previously cited 4/6/19
28 Pa Code 211.12(d)(5) Nursing services
Previously cited 4/6/19
| ||Plan of Correction - To be completed: 01/10/2020|
1. Individual Nurse/s for specific days noted in-serviced on documentation; R-1 not affected by deficient practice.
2. MARS?TARS reviewed for residents to assure completion; No Other residents affected by deficient practice
3. DON in-serviced on checking clinical dashboard daily; In-service for License Nurses on completion of documentation during the time treatment and/or care is given.
4. Audits will be completed daily by DON and submitted weekly and submitted to Nursing Home Administrator to be reviewed monthly as part of the Quality Assurance Performance Improvement Program.