Incomplete Medical Records and Missing POLST Signature
Penalty
Summary
The facility failed to maintain complete and accessible medical records for several residents, specifically lacking medical provider visit notes in both the electronic medical record (EMR) and paper charts. For four residents, there were no medical provider visit notes available in the EMR or in the paper charts at the nurse's desk, despite the residents having been admitted months prior. The process for handling provider notes involved receiving them via facsimile, review by the charge nurse, and subsequent scanning into the EMR, with the original faxed copy placed in the paper chart. However, the most recent notes had not been scanned, and in some cases, no notes were found in either record system. Staff confirmed that a nurse was present during provider visits but did not document the visit in the EMR, and the facility was in the process of changing to direct provider entry into the EMR. Additionally, the facility failed to ensure that a resident's Provider Orders for Life-Sustaining Treatment (POLST) form was properly completed, as one resident's POLST lacked a required physician signature. The unsigned POLST had been carried over from a previous facility and was not identified as incomplete during the admission or care planning process. Facility policy required that advance directives be copied and placed on the chart upon admission and reviewed periodically, but this process did not identify the missing signature.