|§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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for one of seven residents reviewed (Resident 2).
The facility's policy regarding changes in condition, dated November 2018, indicated that the nurse was to record information relative to changes in the resident's medical/mental condition or status in the resident's medical record.
A diagnosis record for Resident 2, dated December 2, 2019, revealed that the resident had diagnoses that included dementia with behaviors, adjustment disorder, alcohol-induced mood disorder and anxiety.
Information submitted by the facility revealed that on December 7, 2019, there was an altercation between Resident 2 and Activity Aide 3. The description of the incident indicated that the resident took a soda from the counter and Activity Aide 3 went to grab it from the resident. The resident became physical with grabbing and slapping the activity aide. Activity Aide 3 slapped the resident and left visible redness on the right side of her face and neck, "which appeared to be finger marks on her right cheek."
Resident 2's medical record contained no documentation that this incident occurred.
Interview with the Assistant Director of Nursing on December 17, 2019, at 1:31 p.m. confirmed that the incident was not documented on Resident 2's medical record.
42 CFR 483.20(f)(5), 483.70(i)(1)-(5) Resident Records - Identifiable Information.
Previously cited 8/13/19, 5/2/19.
28 Pa. Code 211.5(f) Clinical records.
Previously cited 8/13/19, 5/2/19.
| ||Plan of Correction - To be completed: 01/22/2020|
Resident #2 medical record was updated to reflect the incident.
Licensed staff as well as any agency staff will be educated by the Director of Nursing/designee on the facility's documentation requirements and their responsibilities on documenting in the medical record. New staff (including agency staff) coming to the facility will be educated on the facility's documentation requirements and their responsibilities on documenting in the medical record as part of their orientation to the facility.
No system changes made at this time. Incident reports are reviewed daily by Nursing Administration (Director of Nursing/Assistant Director of Nursing/Nurse Educator) to ensure accurate completion of the incident reports.
The daily incident report review does cross over into the clinical record for the nursing note. The Director of Nursing educated the nursing staff which included agency staff on the process of placing their note in the "action tab" of point click care so that it carries over automatically into the clinical record. The nursing administration team will review incident reports daily as part of this review will be monitoring that note is in the clinical record. New facility staff as well as agency staff will be educated on this process as part of the orientation to facility.
Facility will audit 5 charts to ensure to appropriate documentation requirements for four (4) weeks then monthly for two (2) months. Results will be reported and trended through the facility's Quality Assurance Committee.