§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 closed clinical record review and staff interview, it was determined that the facility failed to ensure accurate and complete clinical documentation for one of 3 residents reviewed (Resident CR1).
Findings include:
Review of Resident CR1's closed clinical record revealed that the facility admitted her on January 8, 2024. A physician's order dated January 11. 2024, indicated that nursing staff were to administer Morphine (a narcotic pain reliever) 20 mg (milligrams) per ml (milliliters) .25 ml (milliliters) every one hour as needed for terminal distress.
Interview on January 25, 2024, at 10:15 AM with Employee 1, licensed practical nurse, revealed that on the weekend of January 13, 2024, or January 14, 2024, she prepared a dose of Resident CR1's morphine and handed the syringe to Employee 2, licensed practical nurse, to administer. Employee 2 was visiting Resident CR1 but on medical leave from the facility when Employee 1 let her administer the morphine to Resident CR1. Employee 1 indicated that she signed off Resident CR1's morphine administration as if she gave it on Resident CR1's MAR (Medication Administration Record, a form utilized to document the administration of medications) dated January 2024.
Interview with the Administrator and Director of Nursing on January 25, 2024, at 2:30 PM confirmed the above findings.
28 Pa. Code 211.5 (f)(x) Medical records
28 Pa. Code 211.12 (c)(d)(1)(2)(5) Nursing services
| | Plan of Correction - To be completed: 03/04/2024
1. Resident CR1 no longer resides at NV. Employee #1 has been counseled on the importance of meeting F842 and the Center's policy on Medication Administration Procedures. Employee # 2 will be counseled and re-educated upon return from her medical leave.
2. Don/designee will conduct a sweep of 1 week of medication administration records (MARs) of 5 residents per each unit to confirm that record is accurate and complete in relation the MD order.
3. DON/Designee will conduct education with licensed nurses on the facility policies related to accurate completion of Medication Administration Record.
4. DON/designee will conduct random audit inspections on Medication Administration Procedures (MARs) to confirm accurate completion; audits will be conducted weekly for 4 weeks. Results of the audits will be reported to the QAPI Team.
5. Date of compliance 3/4/2024
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