Failure to Accurately Document and Review Advance Directives and POLST Forms
Penalty
Summary
The facility failed to ensure accurate and complete documentation of residents' wishes regarding their care, specifically related to Advance Directives (AD) and Physician Orders for Life-Sustaining Treatment (POLST) forms, for 12 out of 18 residents reviewed. In several cases, POLST forms were either missing required physician signatures, lacked physician information or license numbers, or were signed by a physician different from the one listed on the form. For example, one resident's POLST was not signed by the physician since January, and another's form was missing both the physician's information and signature. These omissions were confirmed through record reviews and interviews with the Social Services Director (SSD) and Director of Nursing (DON), who acknowledged that the forms should have been properly completed and signed according to facility policy. Additionally, the facility did not consistently document periodic reviews of POLST forms as required by policy. For multiple residents, there was no evidence that the POLST had been reviewed quarterly or annually, either during interdisciplinary team (IDT) meetings or care conferences. The SSD and DON both stated that POLST forms are supposed to be reviewed every three months and at annual assessments, but admitted that this documentation was lacking for several residents. Facility policy requires that the IDT review advance directives with residents during quarterly care planning sessions and document any changes, but this was not done in these cases. Furthermore, there was no documented evidence that residents or their representatives were offered information about formulating an Advance Directive upon admission, nor that ongoing reviews of advance directives were conducted as required. This was the case for all 12 residents identified in the report, regardless of their cognitive status. The facility's own policies and job descriptions require that residents be provided with written information about their rights to accept or refuse treatment and to formulate an advance directive, and that these discussions and any changes be documented in the care plan and medical record. However, interviews with facility staff confirmed that this documentation was not present.