§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 a review of clinical records and staff interviews, it was determined that the facility failed to maintain accurate and complete clinical records for one of 22 sampled residents (Resident 5).
Findings include:
A clinical record review revealed that Resident 5 was admitted to the facility on July 25, 2023, with diagnoses that included chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe) and chronic kidney disease (gradual loss of kidney function).
A physicians order for Resident 5 to receive Cefazolin (an antibiotic medication) sodium injection solution reconstituted to 2.0 g with directions to use 2.0 grams intravenously every eight hours for MRSA (methicillin-resistant Staphylococcus aureus -a type of bacterial infection that can be resistant to antibiotic medications) for 15 days was initiated on August 15, 2025.
A review of Resident 5s medication administration record (MAR) dated August 2025 revealed there was missing documentation for seven scheduled administrations of Cefazolin Sodium Injection Solution Reconstituted 2.0 g. There was no documentation for the administration of cefazolin sodium injection solution reconstituted to 2.0 g on the following dates:
August 18, 2025, at 2:00 PM
August 22, 2025, at 2:00 PM
August 25, 2025, at 2:00 PM
August 27, 2025, at 2:00 PM
August 28, 2025, at 6:00 AM
August 28, 2025, at 2:00 PM
During an interview on September 12, 2025, at 9:00 AM, the Nursing Home Administrator (NHA) indicated that nursing staff omitted the information from the clinical record. The NHA provided an attestation from Employee 1, Registered Nurse (RN), indicating that she administered Resident 5s cefazolin antibiotic medication but forgot to document it in the Electronic Health Record. The NHA confirmed that it is the facilitys responsibility to ensure accurate and complete medical records.
28 Pa. Code 211.5(f)(ii) Medical records.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
| | Plan of Correction - To be completed: 10/14/2025
Step 1
All licensed nurses who would have administered IV antibiotic were interviewed and confirmed they did administer it per physician orders and documented same in the resident chart. There were no left over doses of IV antibiotic to indicate that it was not administered appropriately.
Step 2
To identify others with the potential to be affected, the DON or designee completed a quality assurance lookback audit to ensure all IV medications were administered and signed out as appropriate. Any inconsistencies noted were re-assessed, physician notified as needed and plan of care updated as appropriate.
Step 3
To prevent this from reoccurring, the Staff Development RN or designee completed education with licensed nurses on the facility policy and procedure for IV medication administration and documenting in the EMAR.
To prevent this from reoccurring, all licensed nurses were provided IV administration training.
Step 4
To monitor and maintain ongoing compliance, the DON or designee will quality monitor administration of IV medications 5 days per week for 4 weeks, then weekly for 2 weeks, then monthly for 2 months to ensure no documentation errors or omissions. All findings will be submitted to the QAPI committee for further review and recommendations.
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