Inconsistent Advance Directive Documentation for Life-Sustaining Treatment
Penalty
Summary
The facility failed to ensure that a resident's physician orders, POLST (Pennsylvania Order for Life Sustaining Treatment), and care plan were consistent with each other and accurately reflected the resident's advance directive wishes. Specifically, a review of the clinical record for a resident with diagnoses including kidney failure, GERD, and high blood pressure showed a physician's order and care plan indicating Full Code status, which directs staff to perform CPR in the event of cardiac arrest. However, the resident's POLST, signed by both the resident and physician, indicated DNR (Do Not Attempt Resuscitation), which is a directive to allow natural death and not perform CPR. During an interview, the Director of Nursing confirmed that the physician's orders, POLST, and care plan for this resident were not consistent and acknowledged that all documents should reflect the resident's advance directive wishes. The facility's policy states that a POLST will be honored and should guide care according to the resident or surrogate's wishes, but this was not followed in this case.