§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- (i) Complete; (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.
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Observations:
Based on observations, review of facility policy and clinical records and staff interview, it was determined that the facility failed to maintain accurate and complete documentation related to medication administration for one of 25 residents reviewed (Resident R102).
Findings include:
Review of facility policy entitled "Resident Self-Administration of Medication" dated 10/03/23, indicated that the interdisciplinary team will determine if it is safe for the resident to self-administer drugs before the resident may exercise that right. It also indicated that the interdisciplinary team must determine who will be responsible for the storage and documentation of the administration of drugs and that self-administration of medication will be permitted with the orders of a licensed physician and is monitored by the facility.
Resident R102's clinical record revealed an admission date of 1/19/23, with diagnoses that included schizoaffective disorder (condition with symptoms of schizophrenia and affective disorder at the same time), bipolar disorder, anxiety, and depression.
Observation of medication administration on 2/21/24, at approximately 8:30 a.m. revealed Resident R102 with a bottle of Ipratropium Bromide Nasal spray (medication to treat runny nose caused by colds or allergies) on the bedside tray table. At the time of the observation Resident R102 stated, " I always have my nasal spray on my bedside tray table."
Resident R102's clinical record revealed a physician's order dated 3/01/23, for Ipratropium Bromide Nasal Solution 0.03% two sprays in each nostril as needed for runny nose four times daily.
Resident R102's clinical record lacked a self administration of medication assessment or an order to keep the nasal spray at the bedside. Resident R102's Medication Administration Record (MAR) revealed from the original order date of 3/01/23, to 2/20/204, a period of 11 months and 20 days that Resident R102 was administered the nasal spray on 3/05/23, 3/24/23, 7/22/23, and 7/23/23, a total of four times. A order audit report from the pharmacy for Resident R102 revealed that the nasal spray was ordered on 3/01/23, and re-ordered on 4/10/23, 7/22/23, 9/18/23 and 12/27/23, for a total of 5 bottles that were dispensed from 3/01/23, to 2/20/24.
During an interview on 2/22/2024, at approximately 8:30 a.m. the Nursing Home Administrator confirmed that Resident R102's clinical record lacked documentation regarding the nasal spray administration.
28 Pa. Code 211.5(f)(ii)(iii) Medical records
28 Pa. Code 211.12(d)(1)(5) Nursing services
| | Plan of Correction - To be completed: 04/01/2024
R102 has had a self medication assessment completed and it has been determined that she is no longer safe to self administer her medications.
An initial audit of all residents who currently self administer will be completed to ensure they are able to safely administer their medications.
If a resident is deemed appropriate to self administer their medications they will document their medications on a medication administration record. The nurse on the unit will monitor daily to ensure that the resident is documenting. All nurses will be trained by the Director of Nursing/designee on completing self administration assessments as needed and ensuring residents are documenting their medications. The Nursing Home Administrator/designee will monitor to ensure training is completed.
The Director of Nursing/designee will audit all residents that self administer to ensure they are documenting that they are self administering (5) times a week times two (2) weeks, weekly times two (2) weeks and then monthly times two (2) months.
The Nursing Home Administrator/designee will audit to determine completion.
Pharmacist consultant will review both visually and through proper documentation all residents who self-administer medications to ensure they are safe to self-administer. Pharmacist will report on the monthly pharmacist review results of audit.
Results of the audits will be discussed at the Quality Assurance Process Improvement.
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