St Johns Health Care Corporation
January 23, 2017 Complaint Survey

Standard Health Citations

FF10 483.70(i)(1)(5):RES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE

REGULATION: (i) Medical records. (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 (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: Pattern
Severity: Potential to cause minimal harm
Citation date: January 23, 2017
Corrected date: March 23, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Abbreviated Survey for complaint (#NY 159) completed on 1/23/17, it was determined that for one (Resident #3) of three residents reviewed for abuse, the facility did not maintain clinical records on each resident in accordance with accepted professional standards and practices that was complete, accurately documented and readily accessible. Specifically, the Nursing Kardex was illegible for the number of staff required for bed mobility. This is evidenced by the following: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Nursing Kardex, dated 8/24/16, revealed that the resident was non-ambulatory. Bed mobility was marked, however the amount of assistance/number of staff required was illegible. The Comprehensive Care Plan, dated 8/24/16, included to assist with mobility needs per the kardex. The Minimum Data Set Assessment, dated 8/29/16, revealed the resident has mild cognitive impairment and requires the extensive assistance of two staff for bed mobility and transfers between surfaces. During an interview on 12/9/16 at 1:45 p.m., the Director of Nursing (DON) stated the kardexes are kept in a book at the nurses' station. She said it is policy that staff look at them. The DON stated the Nurse Leader is responsible to update the kardex and ensure that it is legible. She stated the amount of assistance needed for the resident's bed mobility is not legible. Interviews conducted on 12/13/16 included the following: a. At 4:00 p.m., a Licensed Practical Nurse stated she could not read the details of assistance needed for bed mobility on the resident's kardex. b. At 4:15 p.m., a Certified Nursing Assistant (CNA) stated she could not read the details of assistance needed for bed mobility on the resident's kardex. The CNA stated if she cannot read the kardex, she would ask the resident how they move in bed. (10 NYCRR 415.22(a)(1-4))

Plan of Correction: ApprovedFebruary 9, 2017

1. The kardex for Resident #3 was corrected to be legible. Responsible: Nurse Leader Date: 1/24/17
2. All kardexes have been reviewed for legibility and corrected as needed. Responsible: ADON Date: 3/1/17
3. The process for kardex use is being transitioned to a computer generated version throughout the facility. The policy and procedure for Nursing Care Planning has been reviewed and revised to address the new process. Nursing and other clinical staff have been educated on the new process and use of the new kardex tool. Responsible: ADON Date: 3/1/17
4. Audits of the new kardex process will be completed monthly. Audit results will be reported to the QAPI Committee for follow up if needed. Responsible: ADON Date: 3/23/17