Quantum Rehabilitation and Nursing LLC
December 23, 2024 Complaint Survey

Standard Health Citations

FF15 483.20(f)(5),483.70(h)(1)-(5):RESIDENT RECORDS - IDENTIFIABLE INFORMATION

REGULATION: 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.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 23, 2024
Corrected date: N/A

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during the Complaint survey dated 12/17/2024, the facility did not ensure the each resident's medical record was maintained in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are Complete; Accurately documented; Readily accessible; and Systematically organized. Specifically, one Resident (Resident #1) of three residents reviewed for medical records accuracy reflected documentation for neurological checks (an assessment to determine residents level of conciousness, neurological status and vital signs) dated 11/17/2024 at 6:30 AM thru 11/18/2024 at 2PM. Resident #1 was transferred to the hospital dated 11/17/2024 at 4:40PM via 911. The findings are: The review of the Facility Policy for Neurological Checks dated 9/2018 documented Neurological checks will be completed for 24 hours, unless otherwise indicated by the attending physician. Immediately following a head trauma, the physician shall be immediately notified, and neurological checks should be instituted. The time frame for neurological checks was documented in the policy. A brain MRI/CAT scan will be ordered at the discretion of the physician. Observe for symptoms of increased drowsiness, difficulty arousing the resident, increased confusion, and other symptoms. Resident#1, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. It causes altered mental state and confusion.) [MEDICAL CONDITION] varices with bleeding, status [REDACTED]. Functional limitation in range of motion-upper extremity/lower extremity-none, toileting-maximum assistance walk 10 feet with maximum assist. The review of the Comprehensive Care Plan (CCP) documented dated 10/9/2024 Falls / Accidents / Incidents, Potential, at Risk for Falls / Injury, the interventions documented, keep bed in lowest position, frequent rounds while resident in bed. Call bell within reach. Updated for the 11/17/2024 incident dated 11/17/2024 at 7:51AM Resident #1 was crying out this morning, bedside table thrown over, was flipping around in bed screaming, stated they were having a bad dream. Noted bleeding from back of head, small laceration noted. The review of the Progress Note dated 11/17/2024 at 7:51AM documented Resident #1 was observed crying out, bedside table thrown over, Resident #1 was flipping around in bed screaming, states they were having a bad dream. Noted bleeding from back of head, small laceration noted. Psychological services ordered. The review of the Facility Investigation dated 11/17/2024 at 6:45AM documented at 6:45AM the assigned Certified Nurses Aide entered the resident's room heard the resident calling for help. Resident #1 was in bed in low position, with bedside tabletop next to right side of head with red drainage. The Registered Nurse Supervisor assessed the Resident. Full range of motion upper and lower extremities. Pressure dressing applied by the Registered Nurse. Neurological Checks in place. The Medical Doctor was made aware of 1. 0CM open area to right occipital scalp, and the Next of Kin aware. The staff was interviewed. The Medical Doctor ordered to monitor neurological status of the Resident. The investigation concluded no cause to believe any abuse. The review of the progress note dated 11/17/2024 at 7:59PM documented at 4:15PM the next of kin asked the nurse to assess Resident # 1. Neurological checks performed. Resident #1 had a strong grip with left hand, not able to move left arm or left leg. Pupils equal and reactive and included vital signs. The Medical Doctor was made aware and ordered to have Resident #1 sent to hospital for further evaluation. 911 was called and they arrived at about 4:40PM. The review of the Progress Notes dated 11/18/2024 at 7:20AM documented Resident #1 was admitted to the hospital for left sided weakness. The review of the Neurological Observation sheet dated 11/17/2024 documented neurological checks were documented by various staff at 6:30AM, 6:45AM, 7:15AM, 8:15AM, 10:15AM, 12:15AM, 2:15PM,4:15PM and 6:15PM, 8:15PM, 10:15PM 12:15AM 2:15AM 4:14AM 6:15AM and on day 2, (not dated) at 2:00PM. The neurological assessments documented positive response for the assessment despite the 4:15PM nursing progress note documenting Resident #1 had a change in condition requiring hospitalization , The Resident #1 was no longer present in the facility as of 11/27/2024 4:40PM. During and interview conducted with the Director of Nursing on 12/16/2024 at 3:30PM they stated Resident #1 was found flailing both arms in the air, while lying in low bed, in room at a time not recalled. They stated it was reported that the bedside table was lying on the floor on its side, the Resident was assessed to have a small open area on the right side back of head, not actively bleeding. The Registered Nurse Supervisor#2 assessed the resident, called the Next of Kin and also spoke with the Attending Medical Doctor #1, who stated the Resident was alert with eyes reactive to light, alert and not drowsy and the plan was for neurological checks on the set schedule. They further stated they are aware that the staff was documenting Neurological checks on the Neurological Observation Sheet dated 11/17/2024 starting at 6:30AM through 11/18/2024 at 2 :00PM but the Resident transferred out of the facility dated 11/17/2024 at 4:40PM. The staff performing Neurological checks should not have documented anything about Resident #1 if a Resident is not in the facility at the times that are scheduled for those checks. The Director of Nursing stated all of the Nursing staff will be retrained on the Neurological Check Policy starting at this time. 483. 20(f)(5)

Plan of Correction: ApprovedJanuary 14, 2025

The facility acknowledges resident #1 was affected by this deficient practice. Resident #1s Neurological checks sheet was reviewed, to ensure it reflected the appropriate time frame and updated accordingly. A full house audit was conducted on all resident on neurological checks to ensure they are filled out accurately by the director of nursing or designee All current resident on neurological checks were reviewed to ensure compliance with no issues identified A lesson plan was developed for education, and all LPNs and RNs will be educated on accurate documentation in the medical record and specifically the neurological checks. The facility policy on Neurological checks was reviewed on 1/6/25 with no changes made The director of nursing / designee created an audit to ensure all neurological checks are completed Accurately. The director of nursing/ designee will conduct a weekly audit on 10% of all residents on neurological checks to ensure they are completed accurately to ensure compliance x 8 weeks then monthly thereafter until 100% compliance is achieved. Any negative audit findings will be immediately address by the DNS/designee with an onsite teaching/Inservice and disciplinary action as needed. The findings of these audits will be discussed by the DNS/Designee at the QA meetings monthly x3 months, then quarterly in order to review and discuss any unfavorable patterns that may prevent achieving 100% compliance. The director of nursing is responsible for the correction and completion of this deficiency.