Incomplete POLST Forms for Multiple Residents
Penalty
Summary
The facility failed to ensure that the Physician Orders for Life-Sustaining Treatment (POLST) forms were fully completed for six out of eight sampled residents. Specifically, the section regarding advance directives (AD) was left blank on the POLST forms for these residents. Record reviews showed that, despite the residents' admissions and the preparation of their POLST forms, the required section for documenting advance directives was not filled out. This omission was confirmed during a concurrent record review and interview with the Director of Nursing (DON), who acknowledged that nursing staff should have completed all sections of the POLST forms. Facility policies and procedures require that a completed and fully executed POLST form is a legal physician order and must be immediately actionable. Additionally, the policies state that any decision-making regarding a resident's choices should be documented in the medical record and communicated. The failure to complete the advance directive section on the POLST forms for these residents represents noncompliance with these established policies.