Incomplete and Inaccurate POLST Documentation for Multiple Residents
Penalty
Summary
The facility failed to ensure that medical records, specifically the Physician Orders for Life-Sustaining Treatment (POLST) forms, were accurate and complete for three of eight sampled residents. For one resident with dementia and moderate cognitive impairment, the POLST form was missing the physician's phone number, license number, signature, and the responsible party's signature, address, and telephone number. The responsible party's signature was entered by a nurse without indicating it was a verbal consent, and the nurse practitioner’s name was incorrectly entered in the section for the supervising physician. These omissions were verified during a medical record review with a registered nurse. For another resident with moderate cognitive impairment, the POLST form lacked the nurse practitioner's phone number, license number, date signed, and the supervising physician's name. The form also did not indicate whether the information was discussed with the resident, and the resident's address, telephone number, and signature date were missing. A third resident, who was cognitively intact, had a POLST form that did not document a second nurse witnessing the verbal consent from the responsible party, omitted the resident's wishes regarding artificially administered nutrition, and left the responsible party's address and phone number blank. These findings were confirmed by both a registered nurse and the Director of Nursing.