Failure to Document Life-Sustaining Treatment Orders in EHR
Penalty
Summary
The facility failed to ensure that a resident's Physician Order for Life Sustaining Treatment (POLST) was properly entered as a physician's order in the electronic health record (EHR). Although the resident's signed POLST, indicating a desire not to be resuscitated and to avoid certain life-sustaining interventions, was scanned into the EHR under a miscellaneous tab, there was no corresponding physician's order for life-sustaining treatment in the system. The resident confirmed having provided the signed POLST to the facility and expressed her wishes regarding resuscitation and life-sustaining measures. The Director of Nursing stated that staff typically refer to a CPR list posted at the nurse's station to determine code status, but acknowledged that the list was not the most current version. A registered nurse demonstrated that code status should be visible in the EHR, generated by a physician's order, but confirmed that for this resident, no such order was present and the code status was not displayed, indicating a failure to accurately document and communicate the resident's advance directives.