§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 complete and accurate documentation for one of 25 residents reviewed (Resident R11).
Findings include:
No policy was provided on documentation related to tube feeding.
Resident R11's clinical record revealed an admission date of 10/7/14, with diagnoses that included gastrostomy (surgical opening into the stomach for nutritional support), dysphagia (difficulty in swallowing food and liquids, which may interfere with the person's ability to eat and drink) and stroke.
Resident R11's clinical record revealed a physician's order dated 5/20/23, for the enteral feeding of Fibersource HN (nutritional formula) at 50 milliliters (ml) every hour continuous via gastric tube (a total of 400 ml per shift and 1200 ml total of formula). A physician's order dated 2/12/24, for enteral feeding revealed to change the Fibersource HN to 55 ml every hour continuous via gastric tube (a total of 440 ml per shift and 1320 ml total of formula). A physician's order dated 2/12/24, revealed to maintain hydration flush tube with 100 ml water every four hours (200 ml per shift).
Review of the January 2024 Medication Administration Record (MAR) for Resident R11's enteral feeding dated 1/1/24, through 1/31/24, revealed that for day shift the documented ml intake was "X" for 31 of 31 days, for evening shift the documented ml intake was "X" for 30 of 31 days and was blank for one of 31 days, and for the overnight shift the documented ml intake was "X" for 30 of 31 days.
Review of the February 2024 MAR for Resident R11's enteral feeding dated 2/1/24, through 2/29/24, revealed that for day shift the documented ml intake was "X" for four of 29 days and 240 ml below the ordered amount for two of 29 days, for evening shift the documented intake was "X" for three of 29 days, blank for two of 29 days, "NA" for one of 29 days, and 240 ml below the ordered amount for five of 29 days, for the overnight shift the documented ml intake was "X" for two of 29 days, blank for two of 29 days, 240 ml below the ordered amount for one of 29 days, and 390 ml below the ordered amount for one of 29 days.
Review of the February 2024 MAR for Resident R11's every four hour water flush dated 2/12/24, through 2/29/24, revealed that for day shift the documented ml flush was 240 ml over the ordered amount for one of 17 days, for evening shift the documented ml flush was blank for two of 17 days, was "55/hr" for two of 17 days, and was 240 ml over the ordered amount for four of 17 days, for the overnight shift the documented ml flush was blank for one of 18 days, was "50 ml/hr" for one of 18 days, and was 240 ml over the ordered amount for five of 18 days.
Review of the March 2024 MAR for Resident R11's enteral feeding dated 3/1/24, through 3/31/24, revealed that for day shift the documented ml intake was 240 ml below the ordered amount for one of 31 days, for evening shift the documented ml intake was "NA" for two of 31 days, blank for one of 31 days, zero for one of 31 days, 240 ml below the ordered amount for 18 of 31 days, 340 ml below the ordered amount for four of 31 days, and 476 ml above the ordered amount for one of 31 days, for the overnight shift the documented ml intake was blank for two of 31 days, and was 240 ml below the ordered amount for six of 31 days.
Review of the March 2024 MAR for Resident R11's every four hour water flush dated 3/1/24, through 3/31/24, revealed that for day shift the documented ml flush was 240 ml above the ordered amount for one of 31 days, for evening shift the documented ml flush was blank for one of 31 days, "NA" for one of 31 days, was zero for one of 31 days, was 100 ml below the ordered amount for five of 31 days, and was 240 ml above the ordered amount for three of 31 days, for the overnight shift the documented ml flush was blank for two of 31 days and was 240 ml above the ordered amount for three of 31 days.
Review of the April 2024 MAR for Resident R11's enteral feeding dated 4/1/24, through 4/30/24, revealed that for day shift the documented ml intake was 55 ml below the ordered amount for one of 30 days, 110 ml below the ordered amount for one of 30 days, and 240 ml below the ordered amount for one of 30 days, for evening shift the documented ml intake was 55 ml below the ordered amount for one of 30 days, 110 ml below the ordered amount for one of 30 days, 240 ml below the ordered amount for 16 of 30 days, 340 ml below the ordered amount for five of 30 days, and 786 ml above the ordered amount for 1 of 30 days, for the overnight shift the documented ml intake was 240 ml below the ordered amount for five of 30 days.
Review of the April 2024 MAR for Resident R11's every four hour water flush dated 4/1/24, through 4/30/24, revealed for day shift the documented ml flush was 100 ml below the ordered amount for one of 30 days, for evening shift the documented ml flush was zero for one of 30 days, 100 ml below the ordered amount for four of 30 days, 130 ml below the ordered amount for one of 30 days, 200 ml above the ordered amount for one of 30 days, and 240 ml above the ordered amount for three of 30 days, for the overnight shift the documented ml intake was 240 ml above the ordered amount for five of 30 days.
Review of the May 2024 MAR for Resident R11's enteral feeding dated 5/1/24, through 5/8/24, revealed that for evening shift the documented ml intake was blank for one of eight days, 220 ml below the ordered amount for one of eight days, and 240 ml below the ordered amount for four of eight days, for the overnight shift the documented ml intake was 240 ml below the ordered amount for one of eight days.
Review of the May 2024 MAR for Resident R11's every four hour water flush dated 5/1/24, through 5/8/24, revealed that for evening shift the documented ml flush was blank for one of eight days, 20 ml below the ordered amount for one of eight days, 100 ml below the ordered amount for one of eight days, and 100 ml above the ordered amount for one of eight days, for the overnight shift the documented ml flush was 240 ml above the ordered amount for three of eight days.
During an interview on 5/9/24, at approximately 3:02 p.m. the Director of Nursing confirmed that Resident R11's clinical record contained incomplete and inaccurate documentation related to his/her tube feeding formula and water flushes.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 211.12(d)(1)(2)(5) Nursing services
| | Plan of Correction - To be completed: 06/21/2024
Resident 11's clinical record was reviewed by DON or designee. Enternal feeding and flush orders are all appropriate to the needs of the individual residents.
DON or designee at Fairview Manor will monitor to ensure the facility maintains complete and accurate documentation related to tube feeding.
DON to review all tube feed residents currently for appropriate documentation, then educate all Nurses, add monitoring weekly for 3 weeks then monthly for 3 months for accurate documentation
Nursing staff responsible for administration of tube feeding and flush orders as ordered by the physician have been given education regarding accurate documentation.
Results of audits will be reviewed at QAPI.
6/21/24 Date of compliance
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