Incomplete POLST Form in Resident Medical Record
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one resident when the Physician Orders for Life-Sustaining Treatment (POLST) form was found to be incomplete. During interviews and record reviews, it was observed that the POLST for the resident was missing critical information, including the date the form was prepared and the signature of the resident or their legally recognized decisionmaker. Both the LVN and the Director of Nursing confirmed that the POLST was not properly completed, as the required signatures and dates were absent. The resident had a documented history of type 2 diabetes mellitus, depression, muscle weakness, and gait abnormalities, and was assessed as moderately cognitively impaired. The facility's own job descriptions indicated that the Medical Records Clerk was responsible for ensuring records were complete before filing, and the Social Services Director was responsible for overseeing advance care planning and ensuring staff were aware of residents' end-of-life wishes. Despite these responsibilities, the incomplete POLST was scanned into the resident's chart without the necessary signatures. The facility's policy and procedure for medical records accuracy was requested but not provided during the survey.