Incomplete POLST Forms and Missing Advance Directive Documentation
Penalty
Summary
The facility failed to maintain complete Physician Orders for Life Sustaining Treatment (POLST) forms for eight residents, as required by accepted professional standards. Record reviews and interviews revealed that section D of the POLST, which pertains to information regarding advance directives, was left incomplete for these residents. Licensed nursing staff and the Social Service Director confirmed that nurses were responsible for completing this section during admission, but it was not consistently done. One nurse admitted to not completing or following up with section D during her time as an admission nurse, despite recognizing its importance in determining a resident's ability to make decisions regarding care. The affected residents had various significant medical diagnoses, including hemiplegia, hemiparesis, cerebral infarction, femur fracture, paroxysmal atrial fibrillation, hypertensive heart disease with heart failure, cancer, chronic obstructive pulmonary disease, hypertension, dementia, metabolic encephalopathy, and age-related cognitive decline. For example, one resident with intact cognition had a POLST form with section D left blank, and another with moderately impaired cognition also had this section incomplete, as signed by a family member. In each case, the omission meant there was no documentation that the resident or responsible party had been asked about the existence of an advance directive. Facility policy required that medical records be objective, complete, and accurate to facilitate communication among the interdisciplinary team regarding the resident's condition and response to care. The incomplete POLST forms did not provide an accurate representation of the care provided and had the potential to cause confusion among care providers, as noted in staff interviews and policy reviews.