Failure to Update Resident's Care Plan with POLST Preferences
Penalty
Summary
The facility failed to develop and revise a comprehensive, person-centered care plan for a resident with Alzheimer's disease and muscle weakness. The resident's POLST form, completed with the responsible party, indicated a change to a do-not-resuscitate (DNR) status and elected comfort care measures, including selective antibiotic use and no artificial hydration or nutrition. Despite these updates being documented in the physician's orders and progress notes, the resident's care plan was not revised to reflect these specific medical treatment goals. The deficiency was confirmed by the Director of Nursing and the Social Worker, who acknowledged that the care plan did not incorporate the resident's preferences for comfort measures only, antibiotics for comfort, and the decision to forego artificial hydration and nutrition. This oversight was identified during a review of the resident's clinical records and staff interviews, highlighting a failure to align the care plan with the resident's updated medical treatment goals as outlined by the POLST form and the responsible party's instructions.
Plan Of Correction
1. Resident 67's comprehensive care plan has been updated to reflect the POLST, MD orders, progress notes and resident/representative instructions. 2. Residents POLST forms have been reviewed for conformity with MD orders, progress notes and resident/representative instructions. The care plans have the appropriate interventions and goals to meet their individual needs. 3. Facility procedures for developing comprehensive care plans have been reviewed/revised to assure MD orders, progress notes and resident/representative instructions represented on the POLST are included on the comprehensive care plan. The procedures have been in-serviced to the care planning team. 4. The NHA/designee will audit 5 random charts per week to assure MD orders, progress notes and resident/representative instructions represented on the POLST are included on the comprehensive care plan. The audit will be turned in to the QA team for review. 5. February 18, 2025