§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 clinical record review and interview with staff, it was determined that the facility did not maintain complete and accurate medical records related to fall investigation for one of eight records reviewed (Resident R6).
Findings include:
Review of facility reported incidents revealed that resident R6 sustained an unwitnessed fall on January 17, 2025. A request was made to employee E2, the Director of Nursing, at 1:30 p.m. on April 9, 2025, to provide the surveyors with the fall investigation report.
On April 10, 2025, at 9:30 a.m. the facility provided the report. Employee E2 stated that they could not find the original report and that she had "recapitulated" it to a new form. Review of the form revealed that the document was dated as "4-9-25 for event 1-17-25".
Interview with employee E2 on April 10, 2025, at 12:00 p.m. confirmed that because the facility was unable to locate the original document, the records for resident R6 were incomplete.
28 Pa. Code 211.12(c) Nursing service
28 Pa. Code 211.12(d)(1) Nursing service
28 Pa. Code 211.12(d)(2) Nursing service
28 Pa. Code 211.12 (d)(5) Nursing service
| | Plan of Correction - To be completed: 06/08/2025
1.The facility is unable to locate Resident R6's Incident/Accident Report. Resident R6's Medical Record was reviewed - documentation included sufficient information regarding the fall incident on 1/17/2025. The Medical Record documentation included: identifying the fall, evaluation/assessment of resident, immediate interventions implemented, cause of the fall, notification to MD and emergency contact and follow-up interventions. The facility submitted the required PA Dept of Health Reportable Incident on 1/18/2025 which included resident details, details of fall, investigation/cause of fall, immediate interventions and post fall interventions to be implemented.
2. All PA Dept of Health reportable incident events for past 3 months were audited; incident reports were all present.
3. All PA Dept of Health reportable incident events will be entered onto a monthly Incident tracking log by the Director of Nursing /or designee.
4. The incident tracking log will be audited monthly to ensure all reports are present for the next 90 days by the Administrator. Results of the audits will be submitted to QAPI for at the next quarterly QAPI in July 2025. The QAPI committee will determine the need for further submissions.
5. Administrator will in-service DON and nursing supervisors on POC and correction procedures.
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