Incomplete POLST Documentation for Multiple Residents
Penalty
Summary
The facility failed to maintain complete Physician Orders for Life Sustaining Treatment (POLST) forms for three residents. During a review, it was found that the POLST forms for these residents were incomplete, lacking necessary information such as the date the form became effective and the relationship of the person signing the form to the resident. These omissions were confirmed during interviews with a licensed nurse, who acknowledged that the forms should have been fully completed to accurately reflect the residents' wishes regarding life-sustaining treatment. The residents involved had significant medical conditions, including dementia, muscle weakness, adult failure to thrive, hemiplegia, hemiparesis following a stroke, bacteremia, diabetes type 2, endocarditis, autistic disorder, and cognitive communication deficits. The incomplete documentation did not provide an accurate representation of the care provided and had the potential to cause confusion among care providers, as noted in the findings.