16 Del. Admin. Code § 3201-9.0

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

Section 3201-9.0 - Records and Reports

9.1 There shall be a separate clinical record maintained on each resident as a chronological history of the resident's stay in the nursing facility. Each resident's record shall contain current and accurate information including the following:

9.1.1 Admission record which shall include the resident's name, birth date, home address prior to entering the facility, identification numbers (including Social Security), date of admission, physician's name, address and telephone number, admitting diagnoses, name, address and telephone number of resident's representative, the facility's medical record number, and advance directive(s) if applicable.

9.1.2 History and physical examination prepared by a physician within 14 days of the resident's admission to the nursing facility. If the resident has been admitted to the facility from a hospital, the resident's summary and history prepared at the hospital and the resident's physical examination performed at the hospital, if performed within 14 days prior to admission to the facility, may be substituted. A record of subsequent annual medical evaluations performed by a physician must be contained in each resident's file.

9.1.3 A record of post-admission diagnoses.

9.1.4 Physician's orders which include a complete list of medications, dosages, frequency and route of administration, indication for usage, treatments, diets, restrictions on level of permitted activity if any, and use of restraints if applicable.

9.1.5 Physician's progress notes.

9.1.6 Nursing notes, which shall be recorded by each person providing professional nursing services to the resident, indicating date, time, scope of service provided and signature of the provider of the service. Nursing notes shall include care issues, nursing observations, resident change of status and other significant events.

9.1.7 Medication administration record (MAR) including medications, dosages, frequency, route of administration, and initials of the nurse administering each dose. The record shall include the signature of each nurse whose initials appear on the MAR.

9.1.8 Inventory of resident's personal effects upon admission.

9.1.9 Results of laboratory tests, x-ray reports and results of other tests ordered by the physician.

9.1.10 Discharge record which includes date and time, discharge location, and condition of resident.

9.1.11 Special service notes, e.g., social services, activities, specialty consultations, physical therapy, dental, podiatry.

9.1.12 Interagency transfer form, if applicable.

9.1.13 Copies of power(s) of attorney and guardianship, if applicable.

9.1.14 Nutrition progress notes and record of resident weights.

9.1.15 CNA flow sheets.

9.2 Confidentiality of resident records shall be maintained in accordance with the federal Health Insurance Portability and Accountability Act (HIPAA) and 16Delaware Code, § 1121 (6).

9.3 Records shall be retained for 6 years after discharge. For a minor, records shall be retained for three years after age of majority.

9.4 Electronic Record keeping

9.4.1 Where facilities maintain residents' records in electronic format by computer or other devices, electronic signatures shall be acceptable.

9.4.2 The facility shall have a written attestation policy.

9.4.3 The computer network and all devices used to maintain resident medical records shall have safeguards to prevent unauthorized access and alteration of records.

9.4.4 All data entry devices shall require user authentication to access the computer network.

9.4.5 The computer program shall control each person's extent of access to residents' records based on that individual's personal identifier.

9.4.6 The computer's internal clock shall record the date and time of each entry.

9.4.7 An entry, once recorded, shall not be deleted. Alterations or corrections shall supplement the original record.

9.4.8 All entries shall have the date and time of the entry and the individual's personal identifier logged in a file which is accessible to designated administrative staff only.

9.4.9 The computer system shall back up all data to ensure record retention.

9.4.10 The facility shall provide independent computer access to electronic records to satisfy the requirements of the survey and certification process.

9.5 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.

9.6 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.

9.7 Incident reports which shall be retained in facility files are as follows:

9.7.1 All reportable incidents as detailed below.

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

9.7.3 Errors or omissions in treatment or medication.

9.7.4 Injuries of unknown source.

9.7.5 Lost items which are not subject to financial exploitation.

9.7.6 Skin tears.

9.7.7 Bruises of unknown origin.

9.8 Reportable incidents are as follows:

9.8.1 Abuse as defined in 16Delaware Code, § 1131.

9.8.1.1 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.

9.8.1.2 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.

9.8.1.3 Emotional abuse whether staff to resident, resident to resident or any other person to resident.

9.8.2 Neglect, mistreatment or financial exploitation as defined in 16Delaware Code, § 1131.

9.8.3 Resident elopement under the following circumstances:

9.8.3.1 A resident's whereabouts on or off the premises are unknown to staff and the resident suffers harm.

9.8.3.2 A cognitively impaired resident's whereabouts are unknown to staff and the resident leaves the facility premises.

9.8.3.3 A resident cannot be found inside or outside a facility and the police are summoned.

9.8.4 Significant injuries.

9.8.4.1 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.

9.8.4.2 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.

9.8.4.3 Areas of contusions or bruises caused by staff to a dependent resident during ambulation, transport, transfer or bathing.

9.8.4.4 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.

9.8.4.5 A burn greater than first degree.

9.8.4.6 Any serious unusual and/or life-threatening injury.

9.8.5 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.

9.8.6 Suicide or attempted suicide.

9.8.7 Poisoning.

9.8.8 Fire within a facility.

9.8.9 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.

9.8.10 Structural damage or unsafe structural conditions.

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

9.9 The facility shall maintain written policies and procedures, in accordance with 16Delaware CodeChapter 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 § 3201-9.0

13 DE Reg. 1322 (04/01/10)