Inaccurate POLST Documentation of Advance Directive
Penalty
Summary
The facility failed to ensure the accuracy of a resident's medical record, specifically regarding the documentation of the resident's Advance Directive on the POLST form. During a review of the medical record for one resident, it was found that the POLST form indicated the Advance Directive was not available, despite the fact that the document had been uploaded into the electronic medical record several days after the POLST was completed. This discrepancy was confirmed during an interview and concurrent record review with the Social Services Director, who acknowledged that the POLST form should have reflected the presence and review of the Advance Directive in the resident's current medical record. The facility's policy requires that all entries in the medical record be accurate, but this was not followed in the case of the resident's POLST documentation.