16 Del. Admin. Code § 3230-10.0
Current through Register Vol. 28, No. 7, January 1, 2025
Section 3230-10.0 - Records and Reports10.1 There shall be a separate record maintained on each resident. Every resident record shall contain: 10.1.1 Admission record: Including resident's name, birth date, home address prior to entering the facility, identification numbers such as social security, Medicaid, Medicare, etc., date of admission, physician's name, address and phone number, next of kin (relationship, name, address and phone number).10.1.2 History and physical examination: Prepared by physician within (14) days of the residents admission to the home. If the resident has been admitted to the home immediately after discharge from a hospital, the resident's discharge summary, physical examination and history which were prepared at the hospital, if performed within seven (7) days prior to admission to the home, may be substituted in lieu of the above records. Additionally, a record of an annual medical evaluation performed by a physician must be contained in each resident's file.10.1.3 A current individual medication inventory shall be maintained.10.1.5 Discharge records or notes, including place to which discharged.10.1.6 Inter-agency transfer form, if the resident was admitted from an acute facility or any other long term care facility.10.2 Records shall be made available to the resident or the resident's legal representative upon reasonable notice. Otherwise such records shall be held confidential. The consent of the resident or the resident's legal representative shall be obtained before any personal information is released.10.3 Records shall be retained for five (5) years after discharge or three (3) years after death before being destroyed.10.4 Incident reports, with adequate documentation, shall be completed for each incident. 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; 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.10.5 All incident reports whether or not required to be reported shall be retained in facility files for three years. Reportable incidents shall be communicated immediately, which shall be within eight hours of the occurrence of the incident, to the Division of Long Term Care Residents Protection. The method of reporting shall be as directed by the Division.10.6 Incident reports which shall be retained in facility files are as follows: 10.6.1 All reportable incidents as detailed below.10.6.2 Falls without injury and falls with minor injuries that do not require transfer to an acute care facility or neurological reassessment of the resident.10.6.3 Errors or omissions in treatment or medication.10.6.4 Injuries of unknown source.10.6.5 Lost items which are not subject to financial exploitation.10.6.7 Bruises of unknown origin.10.7 Reportable incidents are as follows: 10.7.1 Abuse as defined in 16 Del. C, § 1131. 10.7.1.1 Physical abuse with injury if resident to resident and physical abuse with or without injury if staff to resident or any other person to resident.10.7.1.2 Any sexual act between staff and a resident and any non-consensual sexual act between residents or between a resident and any other person such as a visitor.10.7.1.3 Emotional abuse whether staff to resident, resident to resident or any other person to resident.10.7.2 Neglect, mistreatment or financial exploitation as defined in 16 Del. C., § 1131.10.7.3 Resident elopement under the following circumstances: 10.7.3.1 A resident's whereabouts on or off the premises are unknown to staff and the resident suffers harm.10.7.3.2 A cognitively impaired resident's whereabouts are unknown to staff and the resident leaves the facility premises.10.7.3.3 A resident cannot be found inside or outside a facility and the police are summoned.10.7.4 Significant injuries. 10.7.4.1 Injury from an incident of unknown source in which the initial investigation or evaluation supports the conclusion that the injury is suspicious. Circumstances which may cause an injury to be suspicious are: 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.10.7.4.2 Injury which results in transfer to an acute care facility for treatment or evaluation or which requires periodic neurological reassessment of the resident's clinical status by professional staff for up to 24 hours.10.7.4.3 Areas of contusions or bruises caused by staff to a dependent resident during ambulation, transport, transfer or bathing.10.7.4.4 Significant error or omission in medication/treatment, including drug diversion, which causes the resident discomfort, jeopardizes the resident's health and safety or requires periodic monitoring for up to 48 hours.10.7.4.5 A burn greater than first degree.10.7.4.6 Any serious unusual and/or life-threatening injury.10.7.5 Entrapment which causes the resident injury or immobility of body or limb or which requires assistance from another person for the resident to secure release.10.7.6 Suicide or attempted suicide.10.7.8 Fire within a facility.10.7.9 Utility interruption lasting more than eight hours in one or more major service including electricity, water supply, plumbing, heating or air conditioning, fire alarm, sprinkler system or telephones.10.7.10 Structural damage or unsafe structural conditions.10.7.11 Water damage which impacts resident health, safety or comfort.10.8 The facility shall maintain written policies and procedures, in accordance with 16 Del. C. Chapter 25, regarding health care decisions including advance directives. The facility shall provide written information to all residents explaining such policies and procedures.16 Del. Admin. Code § 3230-10.0