§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(h) Medical records.
§483.70(h)(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(h)(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(h)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.
§483.70(h)(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(h)(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 the review of facility policy, observations, clinical records, and staff interviews, it was determined that the facility failed to appropriately document treatments for two of four residents (Residents R4 and R1).
Findings include:
Review of the facility policy, "Charting and Documentation" dated 1/8/26, previously dated 1/14/25, indicated "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, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care."
Review of the facility policy, "Dressings, Dry/Clean" dated 1/8/26, previously dated 1/14/25, indicated for staff to document that date and time the dressing was changed.
Review of the clinical record indicated Resident R4 was admitted to the facility on 2/12/25.
Review of the Minimum Data Set (MDS - periodic assessment of resident care needs dated 2/19/26, included diagnoses of atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and osteomyelitis (inflammation of bone or bone marrow, usually due to infection).
Review of the plan of care dated 2/13/26, indicated that Resident R4 had actual skin impairment related to an incision and drainage/osteomyelitis. Included in the interventions was, "Wound vac dressing changes three times per week on M-W-F (Monday, Wednesday, Friday)."
Review of a physician's order dated 2/13/26, indicated that Resident R4's wound vac dressing to be changed three times per week on Monday, Wednesday, and Friday on day shift.
During an interview on 3/4/26, at 2:45 p.m. Licensed Practical Nurse (LPN) Employee E2 stated Resident R4 had not had his wound vac dressing change completed yet that day.
Review of Resident R4's Treatment Administration Record (TAR) for March 2026, on 3/4/26, at 2:50 p.m. revealed that LPN Employee E2 had documented that she had completed the wound vac dressing change.
During an interview on 3/4/26, at 2:55 p.m. when asked to confirm if Resident R4's wound vac dressing change had been completed as she had stated it was not done, but had documented that it was done, LPN Employee E2 stated that LPN Employee E3 had completed the dressing change.
During an interview on 3/4/26, at 3:02 p.m. LPN Employee E3 stated she had not completed Resident R4's dressing change.
Review of the clinical record indicated Resident R1 was admitted to the facility on 12/3/25.
Review of the MDS dated 12/9/25, included diagnoses of paraplegia and neurogenic bladder. Review of Section C: Cognitive Patterns indicated that Resident R1 was cognitively intact.
Review of the plan of care dated 3/3/26, indicated that Resident R1 had actual skin impairment related to impaired mobility. Included in the interventions was, "Administer treatment per physician order.".
Review of a physician's order dated 3/3/26, indicated that Resident R1 was to have dressing changes to sacral wound: "Clean with acetic acid 1%, apply zinc oxide to peri wound, apply collagen, calcium alginate and apply abd (medical dressing) bid (twice daily) and prn (as needed)."
During a dressing change observation completed on 3/5/26, at 2:00 p.m. the soiled dressing removed was noted to be dated 3/3/26, without a documented time or staff member who performed the dressing change.
During an interview, completed during the observed dressing change, on 3/5/26, at approximately 2:10 LPN Employee E4 stated that Resident R4's dressing change was to be completed once daily. At this time, Resident R4 responded to LPN Employee E4's comment and stated that he had not had twice daily dressing changes, "in a very long time."
Review of Resident R4's Treatment Administration Record (TAR) for March 2026, on 3/5/26, at 2:25 p.m. confirmed that Resident R4 was to receive twice daily dressing changes and confirmed that LPN Employee E2 had documented that she completed both the morning and evening dressing changes on 3/4/26.
During an interview on 3/5/26, at 2:30 p.m. the Nursing Home Administrator and the Director of Nursing were informed that the dressing removed from Resident R4 during the dressing change observation on 3/5/26, was dated 3/3/26, and that incorrect information was entered on the TAR documenting that dressing changes were completed by LPN Employee E2 on 3/4/26, for both the day and evening dressing change.
During an interview on 3/6/26, at approximately 12:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to appropriately document treatments for two of four residents.
28 Pa. Code: 211.5(f)(g)(h) Clinical records.
| | Plan of Correction - To be completed: 04/14/2026
Resident R1 and R4 immediately had their dressing changed. Employee E2 was educated and suspended pending investigation, and an ERS was submitted to the Department of health. No other residents were identified from this deficient practice. An audit was completed at time of survey of all current residents with dressing change orders to make sure they were completed an dated appropriately. Licensed nurses educated on the facility wound care policy and completing the dressing changes as ordered and not signing off until dressing is completed by CNO. The DON/designee will complete audits 3 times a weeks for 2 weeks and monthly times 2 months to ensure wound dressings are changed and dated per physicians orders. The results will be reviewed at the Quality Assurance and Process Improvement meetings until substantial compliance has been met.
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