Contradictory POLST and Code Status Documentation for a Resident
Penalty
Summary
The facility failed to ensure that a resident's end-of-life wishes and emergent treatment preferences were accurately documented and consistent across medical records. Specifically, the resident's POLST (Physician Orders for Life Sustaining Treatment) form and the electronic medical record contained contradictory code status selections. The POLST form had both 'Do Not Attempt Resuscitation/DNR' and 'Full Treatment' options marked, which are mutually exclusive. The electronic physician's order also reflected this contradiction by listing the resident as DNR with full treatment. These inconsistencies were confirmed during interviews and record reviews with licensed nursing staff, who acknowledged that the documentation was confusing and could result in the resident not receiving care according to their wishes. The resident in question was admitted with multiple diagnoses, including cerebral infarction and vascular dementia. Interviews with the resident's representative clarified that the resident did not want CPR or any life-prolonging interventions if their heart or breathing stopped. The Director of Nursing confirmed that the POLST was completed incorrectly and was contradictory, acknowledging that such errors could lead to the resident receiving care that was not in line with their expressed preferences. Facility policy required review of POLST forms for validity upon completion, but this process failed to prevent the error.