Incomplete Medical Records and Personal Effects Inventories
Penalty
Summary
The facility failed to ensure that medical records and inventories of personal effects for four residents were accurate and complete, as required by facility policy and accepted professional standards. Specifically, for three residents, the Inventory of Personal Effects forms were not reviewed with or signed by the residents' representatives upon admission, with signature sections left blank and undated on multiple occasions. The Director of Nursing (DON) confirmed that these inventories were completed by CNAs at admission but acknowledged that the forms should have been fully completed to account for all personal belongings. Additionally, two residents had incomplete Physician Orders for Life-Sustaining Treatment (POLST) forms. The missing information included the physician's telephone number, license number, and the resident's or responsible party's signature, address, and phone number, as well as the date the POLST was completed. The DON verified these omissions and stated that the POLST forms were completed by RNs at admission and followed up by social services staff, but should have been fully filled out as they contain relevant medical information.