16 Del. Admin. Code § 3225-19.0

Current through Register Vol. 28, No. 5, November 1, 2024

Section 3225-19.0 - Records and Reports

19.1 The assisted living facility shall be responsible for maintaining appropriate records for each resident. These records shall document the implementation of the service agreement for each resident.

19.2 Records shall be available, along with the equipment to read them if electronically maintained, at all times to legally authorized persons; otherwise such records shall be held confidential.

19.3 The assisted living facility resident clinical records shall be retained for a minimum of 5 years following discharge or 3 years after death before being destroyed.

19.4 In cases in which facilities have created the option for an individual's record to be maintained by computer, rather than hard copy, electronic signatures shall be acceptable. In cases when such attestation is done on computer records, safeguards to prevent unauthorized access and reconstruction of information must be in place. The following is an example of how such a system may be set up:

19.4.1 There is a written policy, at the assisted living facility, describing the attestation policy(ies) force at the facility;

19.4.2 The computer has built-in safeguards to minimize the possibility of fraud;

19.4.3 Each person responsible for an attestation has an individualized identifier;

19.4.4 The date and time is recorded from the computer's internal clock at the time of entry;

19.4.5 An entry is not to be changed after it has been recorded; and

19.4.6 The computer program controls what sections/ areas any individual can access/enter data based on the individual's personal identifier.

19.5 Incident reports, with adequate documentation, shall be completed for each incident. Records of incident reports shall be retained in facility files for the following:

19.5.1 All reportable incidents.

19.5.2 Falls without injury and falls with injuries that do not require transfer to an acute care facility or do not require reassessment of the resident.

19.5.3 Errors or omissions in treatment or medication.

19.5.4 Injuries of unknown source.

19.5.5 Lost items, in accordance with facility policy, which are not subject to financial exploitation. Adequate documentation shall consist of the name of the resident(s) involved; the date, time and place of the incident; a description of the incident; a list of other parties involved, including witnesses and any accused persons; the nature of any injuries; resident outcome; and follow-up action, including notification of the resident's representative or family, attending physician and licensing or law enforcement authorities when appropriate.

19.6 Reportable incidents shall be reported immediately, which shall be within 8 hours of the occurrence of the incident, to the Division. The method of reporting shall be as directed by the Division.

19.7 Reportable incidents include:

19.7.1 Abuse as defined in 16Del.C.§ 1131.

19.7.1.1 Physical abuse.

19.7.1.1.1 Staff to resident with or without injury.

19.7.1.1.2 Resident to resident with or without injury.

19.7.1.1.3 Other (e.g., visitor, relative) to resident with or without injury.

19.7.1.2 Sexual abuse.

19.7.1.2.1 Staff to resident sexual acts.

19.7.1.2.2 Resident to resident non-consensual sexual acts.

19.7.1.2.3 Other (e.g., visitor, relative) to resident non-consensual sexual acts.

19.7.1.3 Emotional abuse.

19.7.1.3.1 Staff to resident.

19.7.1.3.2 Resident to resident.

19.7.1.3.3 Other (e.g., visitor, relative) to resident.

19.7.2 Neglect as defined in 16Del.C.§ 1131.

19.7.3 Mistreatment as defined in 16Del.C.§ 1131.

19.7.4 Financial exploitation as defined in 16Del.C.§ 1131.

19.7.5 Resident elopement.

19.7.5.1 Any circumstance in which a resident's whereabouts are unknown to staff and the resident suffers harm.

19.7.5.2 Any circumstance in which a cognitively impaired resident, whose whereabouts are unknown to staff, exits the facility.

19.7.5.3 Any circumstance in which a resident cannot be found inside or outside a facility and the police are summoned.

19.7.6 Death of a resident in a facility or within 5 days of transfer to an acute care facility.

19.7.7 Significant injuries.

19.7.7.1 Injury from an incident of unknown source in which the initial investigation concludes that there is reasonable basis to suspect that the injury is suspicious. An injury is suspicious based on; the extent of the injury, the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma), the number of injuries observed at one particular point in time or the incidence of injuries over time.

19.7.7.2 Injury from a fall which results in transfer to an acute care facility for treatment or evaluation or which requires periodic reassessment of the resident's clinical status by facility professional staff for up to 48 hours.

19.7.7.3 Injury sustained while a resident is physically restrained.

19.7.7.4 Injury sustained by a resident dependent on staff for toileting, mobility, transfer and/or bathing.

19.7.7.5 Medication error or omission which causes or prolongs the resident's discomfort, jeopardizes the resident's health or safety, or requires periodic reassessment of the resident's clinical status by facility professional staff.

19.7.7.6 Treatment error or omission which causes or prolongs the resident's discomfort, jeopardizes the resident's health or safety, or requires periodic reassessment of the resident's clinical status by facility professional staff.

19.7.7.7 A burn greater than first degree.

19.7.7.8 Choking resulting in transfer to an acute care facility.

19.7.7.9 Areas of contusions or lacerations which may be attributable to abuse or neglect.

19.7.7.10 Serious unusual and/or life-threatening injury.

19.7.8 Attempted suicide.

19.7.9 Poisoning.

19.7.10 Epidemic outbreak or quarantine.

19.7.11 Circumstances which provide a reasonable basis to suspect that a resident's drugs have been diverted.

19.7.12 Utility interruption lasting more than 8 hours in one or more major service including electricity, water supply, plumbing, heating or air conditioning, fire alarm, sprinkler system or telephone system.

19.7.13 Structural damage or unsafe structural conditions.

19.7.13.1 Structural damage to a facility due to natural disasters such as hurricanes, tornadoes, flooding or earthquakes.

19.7.13.2 Water damage which impacts resident health, safety or comfort.

16 Del. Admin. Code § 3225-19.0

8 DE Reg. 85 (7/1/04)
13 DE Reg. 1328 (04/01/10)
15 DE Reg. 1156 (02/01/12)