|§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 ensure that residents' clinical records were complete and accurately documented for one of 11 residents reviewed (Resident 5).
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated January 22, 2020, revealed that the resident was cognitively impaired, had diagnoses that included a hip fracture and obstructive uropathy (difficulty passing urine), and had an indwelling urinary catheter (tube inserted and held in the bladder to drain urine).
A nursing note for Resident 5, dated January 5, 2020, indicated that the resident was usually incontinent of urine and that she had an indwelling urinary catheter. A nursing note, dated January 18, 2020, indicated that the resident had an indwelling catheter that was draining medium yellow urine, and a note dated January 23, 2020, indicated that the resident had an indwelling catheter.
However, nursing notes dated January 20, 21 and 23, 2020, indicated that the resident was incontinent of bladder.
Interview with the Director of Nursing on February 28, 2020, at 2:35 p.m. confirmed that staff documented inaccurately that Resident 5 was incontinent of bladder.
28 Pa. Code 211.5(f) Clinical records.
28 Pa. Code 211.12(d)(5) Nursing services.
| ||Plan of Correction - To be completed: 04/13/2020|
1. Education was provided to the licensed staff who documented 'incontinent" on a resident with an indwelling catheter.
2. Residents with indwelling catheters had a nursing progress note review performed for correct documentation regarding continent status.
3. The licensed staff, including new hires and agency, will be educated on the proper documentation procedures and accuracy for continence status for residents with indwelling catheters.
4. An audit of residents' charts with indwelling catheters will be performed by the Director of Nursing three times a week for four weeks to ensure accurate documentation of urinary continence status. The results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee.
5. Date of Compliance: 4/13/2020