Failure to Maintain Accurate Resident Property Inventory and End-of-Life Documentation
Penalty
Summary
The facility failed to maintain an accurate and complete inventory of a resident's personal belongings, as well as failed to document the disposition of those belongings upon the resident's discharge. One resident's medical record did not contain an inventory of personal items, including a motorized wheelchair and marijuana, despite staff acknowledging the presence and storage of these items. There was no documentation regarding the final disposition of these belongings after the resident was transferred to the hospital, and the facility was unable to provide a policy specific to the inventory of residents' belongings beyond a general admission policy. Additionally, the facility did not ensure accurate and complete documentation of residents' end-of-life choices. For another resident, the electronic medical record (EMR) indicated a code status of 'Full Code,' while the paper record contained an active MOLST form indicating 'Do Not Resuscitate/Do Not Intubate' (DNR/DNI) status. Staff interviews revealed reliance on both the EMR and paper chart for code status, but discrepancies existed between the two sources. The resident's care plan and a nurse practitioner's note also contained conflicting information regarding code status, and two active MOLST forms with different directives were found in the medical record. These deficiencies were evident during a complaint survey and were confirmed through record review, staff interviews, and observation. The lack of a consistent process for documenting and updating both personal property inventories and end-of-life directives led to incomplete and conflicting records for the residents involved.