Failure to Complete POLST and Advance Directive Forms Upon Re-Admission
Penalty
Summary
The facility failed to ensure that the Physician Orders for Life-Sustaining Treatment (POLST) and Advance Directive (AD) Acknowledgement Form were completed upon the re-admission of a resident. Record review showed that the resident, who had diagnoses including diabetes mellitus, end stage renal disease, and hypertension, was readmitted to the facility but did not have updated POLST and AD forms as required by facility policy. The resident's Minimum Data Set indicated moderately impaired cognition and a high level of dependence on staff for daily activities. Interviews with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that the required POLST and AD Acknowledgement Form were not completed or updated at the time of re-admission. Facility policy states that these forms should be completed and reviewed with every admission and re-admission to ensure care aligns with the resident's current wishes. The absence of these documents was verified through review of the resident's medical record and the facility's electronic health record system.