Incomplete and Inaccurate POLST Documentation
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to accurately complete and maintain Physician Orders for Life-Sustaining Treatment (POLST) forms for two residents. For one resident, the POLST form did not contain the resident's correct first name, as it was neither the resident's first name, middle name, nor a name the resident used. For another resident, the required signature of the patient or their decision-maker was missing from the POLST form that was placed in the electronic health record (EHR). Staff interviews confirmed that social services are responsible for reviewing and ensuring the accuracy of POLST forms upon admission, and that the code status on the POLST should match the EHR and be properly signed.