Failure to Ensure POLST and Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that a resident's Pennsylvania Order for Life Sustaining Treatment (POLST) and physician orders were consistent and accurately reflected the resident's or their representative's wishes regarding life-sustaining treatment. Review of the clinical record for a resident with diagnoses including dementia, anxiety, and gastroesophageal reflux disease showed that the POLST form was incomplete, lacking documentation of the resident's or representative's advance directive wishes. Additionally, the only documented order in the clinical record was for Full Code (CPR), with no evidence that the resident or their representative had been provided written information on advance directives or assisted in formulating such directives. During staff interview, a registered nurse confirmed that the POLST for this resident did not reflect the required information and had not been properly completed or signed by a physician to indicate the resident's current wishes. The nurse also acknowledged that staff rely on the paper chart to determine life-sustaining treatment preferences during emergencies, but in this case, the necessary documentation was missing. This deficiency was cited under multiple Pennsylvania state codes related to management, resident rights, medical records, and resident care policies.