Incomplete Medical Records and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure the completeness and accuracy of medical records for multiple residents, particularly in the areas of advance directives, beneficiary notices, and nutrition documentation. For several residents, Physician Orders for Scope of Treatment (POST) forms were incomplete, lacking required signatures from authorized representatives or witnesses, and in some cases, there was no documentation of follow-up to obtain these signatures. The Social Worker acknowledged that there was no official process for securing written consent after verbal acknowledgments, and forms were often not mailed to out-of-state representatives, resulting in incomplete documentation. In one instance, a POST form listed the Department of Health and Human Resources as the official surrogate, but there was no documentation of communication regarding the transition of decision-making authority or confirmation of who currently held legal authority. In addition to deficiencies with POST forms, the facility did not properly complete Advance Beneficiary Notices (ABNs) for two residents. Verbal consent was obtained from representatives, but there was no attempt to follow up with mailed, emailed, or faxed notices as required by facility policy. The Social Worker confirmed that only verbal consent was obtained and cited concerns about postage as a reason for not sending the forms. Facility policy required that if a notice could not be hand-delivered, it should be followed up immediately with a mailed, emailed, faxed, or hand-delivered notice, and documentation should comply with form instructions regarding telephone notices. There was also an error in the documentation of a resident's admission weight. The admission weight recorded in the chart was inconsistent with the weight documented by the hospital and the weight assessed by the Registered Dietician. The DON confirmed that the admission weight in the chart was incorrect and should have been corrected. These failures in documentation and record-keeping led to incomplete and inaccurate medical records for the affected residents.