Incomplete Medical Records and Documentation Errors
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents. For one resident, the Physician's Order for Scope of Treatment (POST) form dated 01/31/25 was found to be incomplete, specifically missing a documented choice in Section D regarding medically assisted nutrition options. This omission was confirmed by both the Administrator and the DON. For another resident, a review of transfer documentation revealed that the date on the second hospital transfer form was incorrect, listing an earlier year instead of the actual transfer date. The Administrator confirmed that the incorrect dates were due to a system issue. These findings were based on record reviews and staff interviews conducted during the survey process, affecting two of the 22 residents reviewed.