§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.
|
Observations:
Based on review of facility policies, clinical records and staff interview, it was determined that the facility failed to make certain that medical records on each resident are complete and accurately documented for two of eight residents (Resident R6 and R13).
A review of the facility policy "Nursing Department Documentation" dated 7/30/25, indicated that nursing department is responsible for maintaining appropriate documentation.
A review of the facility policy " Medical Records " dated 7/30/25, indicated the facility is to maintain hospital records in a neat and organized manner.
A review of the clinical record indicated that Resident R6 was admitted to the facility on 7/19/24, with diagnoses that included vascular dementia, major depressive disorder, and anxiety.
A review of Resident R6's after visit summary from neurologist dated 12/3/24, indicated a new diagnosis of Parkinsonism. This was reviewed by facility, as confirmed with signature and dated 12/4/24.
A review of the Minimum Data Set (MDS-periodic assessment of resident care needs) dated 5/12/25, indicated " no " for the diagnose of Parkinson ' s disease.
A review of Resident R6 ' s order summary dated 6/11/25, indicated Resident R6 was ordered Carbidopa-Levodopa 25-100 mg tablet for Parkinson ' s disease.
A review of Resident R6 ' s care plan dated 10/23/25, indicated no mention of Parkinson ' s disease.
Review of the clinical record indicated Resident R13 was admitted to the facility on 6/16/22.
Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 8/27/25, included diagnoses of dysphagia oropharyngeal phase (disruption or delay in swallowing), conduction disorder (electrical impulses that coordinate heartbeats are delayed or blocked), and high blood pressure.
Review of the physician order dated 12/11/24, indicated Resident R13 is strict NPO (nothing by mouth).
Review of the physician order dated 10/19/25, indicated Resident R13 is ordered Lasix oral tablet by mouth (water pill prevents salt absorption) 40 milligrams twice daily.
Review of Resident R13 ' s plan of care intervention initiated 6/27/22, indicated to administer medication as order.
Review of Resident R13 ' s Medication Administration Records for Lasix's from 10/19/25, through 10/24/25, revealed the following:
10/19/25: medication administered (evening dose).
10/20/25: medication administered (morning dose).
10/20/25: medication administered (evening dose).
10/21/25: medication administered (morning dose).
10/21/25: medication administered (evening dose).
10/22/25: medication administered (morning dose).
10/22/25: medication administered (evening dose).
10/23/25: medication administered (morning dose).
10/23/25: medication administered (evening dose).
10/24/25: medication administered (morning dose).
During an interview, on 10/24/25, at approximately 9:30 a.m., with the Director of Nursing (DON), confirmed the medication was ordered and documented as administered orally and was able to confirm all doses had been administered enterally according to R13 strict NPO status.
During an interview on 10/24/25, at 10:15 a.m. the Director of Nursing confirmed the above findings, and the facility failed to make certain that medical records on each resident are complete and accurately documented for Resident R6 and Resident R13.
28 Pa. Code: 211.5(f)(g)(h) Clinical records
| | Plan of Correction - To be completed: 11/28/2025
The care plan of Resident R6 was updated with Parkinson's Disease diagnosis on 10-24-2025 and the MDS will be updated upon next review date by the RNAC.
The consultant pharmacist has done an audit on all current residents to make sure each medication is associated with an appropriate diagnosis that is also represented on the diagnosis list.
As of November 3, 2025, the consultant pharmacist began a new process of cross-referencing all newly prescribed medications with supporting diagnosis.
The internal report of consultation sheet that accompanies the after-visit summary from consulting physician visits, has been updated to include the direction to forward information to the RNAC for review and necessary alterations to the MDS and care plan. Both the internal report of consultation sheet and the after-visit summary from consulting physician visits will be forwarded to the RNAC. All RN's and LPN's will be educated on the revised form by the Administrator or designated person.
The physician order of Resident R13 to administer Lasix by mouth was changed on October 24, 2025 due to strict NPO status.
There are currently no other Residents who are a strict NPO status that would be affected.
The RNAC will review all medication orders of residents with a strict NPO status to ensure proper route of medication administration is correct on the physician's order and MAR.
The Director of Nursing, or designee, will monitor the consultant pharmacist reports and medication orders of strict NPO residents daily for one month, weekly for one month and monthly for two months. Summary of findings will be reported in quarterly QAPI meetings.
|
|
