Inconsistent Documentation of Advance Directives and POLST Forms
Penalty
Summary
The facility failed to ensure that documentation regarding advance directives and Physician Orders for Life Sustaining Treatment (POLST) was accurate and consistent for two of five sampled residents. For one resident with chronic systolic heart failure and type 2 diabetes, the POLST indicated the presence of an advance directive, while the Advance Directive Acknowledgment form stated otherwise, and no advance directive was found in the medical chart. The Social Services Director confirmed the inconsistency and acknowledged that the information should have been clarified and updated to reflect the resident's wishes. For another resident with chronic respiratory failure and hypertensive heart disease, the POLST indicated no advance directive, but the Advance Directive Acknowledgment form stated that one existed. The Social Services Director was unable to determine which staff member completed the form and confirmed the mismatch between the documents. The facility's policy requires honoring residents' rights to formulate and have advance directives, but the inconsistent documentation failed to ensure that staff would have accurate information about residents' wishes in the event of a medical emergency.