|§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 clinical record reviews and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 57 residents reviewed (Resident 174).Findings include:Physician's orders for Resident 174, dated January 3, 2020, included an order to measure the resident's coccyx (tailbone area) wound three times a week and then document the measurements in the electronic medical record every evening shift on Monday, Wednesday, and Friday. Resident 174's Treatment Administration Record (TAR) for January 2020 revealed that staff signed off that they completed the measurement on January 3, 20 and 22, 2020; however, there was no documented evidence that the wound measurements were placed into the resident's electronic medical record. Interviews with Licensed Practical Nurse Unit Coordinator 7 and the Director of Nursing on January 24, 2020, at 11:24 a.m. and 3:25 p.m. confirmed that Resident 174's TAR indicated that wound measurements were completed, but the measurements were not documented in the resident's electronic medical record on the above dates. 42 CFR 483.20(f)(5), 483.70(i)(1)-(5) Resident Records - Identifiable InformationPreviously cited 7/10/19. 28 Pa. Code 211.5(f) Clinical records.Previously cited 7/10/19, 2/28/19. 28 Pa. Code 211.12(d)(3) Nursing services.Previously cited 9/20/19, 7/10/19, 2/28/19.
| ||Plan of Correction - To be completed: 03/17/2020|
1.Resident 174 physician notified and order received for wound measurements one time er week.
2.All residents with wounds have the potential to be affected by this alleged deficient practice.
audit of residents with wounds completed no further issues noted
3.Licensed clinical nursing staff and agency staff will be re-educated on the facility pressure sore policy including the need to document wound measurements in accordance with facility policy
Wound Measurements will be reviewed on a weekly basis.
4. Director Of Nursing or designee will conduct random audits of residents with wounds to ensure documentation is complete. Audits will be completed weekly x 4 and monthly x3.
Findings will be reviewed by the
Quality Assurance Performance
Improvement Committee during
monthly meetings x 3 months or until substantial compliance