§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 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 refusal of medications for one of three residents reviewed (Resident R4).
Findings include:
Review of facility policy entitled "Charting and Documentation" dated 1/10/24, revealed that the "residents medical record is a concise account of treatment, care, response to care, signs, symptoms, and progress of resident's condition" and it is a "written support of care and services provided" and serves as "communication among caregivers who are providing services."
Resident R4's clinical record revealed an admission date of 6/29/22, with diagnoses that included diabetes, high blood pressure, and depression.
Resident R4's clinical record revealed a physician's order dated 12/7/23, for Insulin Lispro 10 units subcutaneous (sq - injected into the tissue between the skin and muscle) daily at 11:30 a.m. Resident R4's Medication Administration Record (MAR) revealed Resident R4's 11:30 a.m. insulin was held on 1/1/24, 1/6/24, and 1/7/24, due to blood sugar results and on 1/10/24, indicating coverage was not needed.
Resident R4's clinical record revealed a physician's order dated 1/11/24, for Insulin Lispro 5 units sq daily at 11:30 a.m. Resident R4's MAR revealed Resident R4's 11:30 a.m. insulin was held on 1/20/24, indicating coverage was not needed.
Resident R4's clinical record revealed a physician's order dated 1/23/24, for Insulin Lispro 4 units sq daily at 11:30 a.m. Resident R4's MAR revealed Resident R4's 11:30 a.m. insulin was held on 1/29/24, due to blood sugar results.
Resident R4's clinical record revealed a physician's order dated 1/4/23, for Insulin Lispro 15 units sq daily at 4:30 p.m. Resident R4's MAR revealed Resident R4's 4:30 p.m. insulin was held on 1/9/24, and 1/19/24, indicating coverage was not needed, and on 1/13/24, indicating vital signs were outside parameter.
Resident R4's clinical record revealed a physician's order dated 1/22/24, for Insulin Lispro 13 units sq daily at 4:30 p.m. Resident R4's MAR revealed Resident R4's 4:30 p.m. insulin was held on 1/22/24, indicating coverage was not needed.
Resident R4's clinical record revealed a physician's order dated 1/4/24, for Lantus (type of insulin) 33 units sq daily at 4:30 p.m. Resident R4's MAR revealed Resident R4's 4:30 p.m. insulin was held on 1/13/24, indicating vital signs were outside parameter.
Resident R4's clinical record revealed a physician's order dated 12/28/23, for Lantus 33 units sq daily at 9:00 p.m. Resident R4's MAR revealed Resident R4's 9:00 p.m. insulin was held on 1/2/24, indicating coverage was not needed.
During an interview on 2/2/2024, at approximately 12:19 p.m. Nursing Home Administrator (NHA) and Director of Nursing (DON) stated that Resident R4 will often time refuse his/her insulin. NHA and DON also confirmed that Resident R4's physician's order lacked parameters for holding insulin and was for routine insulin administration and not based on a sliding scale requiring coverage. NHA and DON stated they believed all the dates and times indicated above were times Resident R4 refused his/her insulin and staff inaccurately documented that on the MAR.
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: 03/04/2024
The Director of Nursing/Designee will review of all resident records on residents who received insulin in the last 30 days to ensure accurate and complete documentation related to refusal of insulin. Additionally, physician orders for insulin will be reviewed to ensure parameters are included as needed. Assistant Director of Nursing/designee will monitor the Director of Nursing to ensure completion.
Resident R4 and all other resident refusals of insulin will be documented. All nurses will be educated on insulin refusal documentation.
The Assistant Director of Nursing/Designee will audit the medication administration record for insulin refusal five times a week times two weeks, weekly times two weeks and monthly times two months. Corrective action will take place as needed.
Results of the audit will be discussed at the monthly quality assurance meeting.
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