Inaccurate Completion of POLST Due to Lack of Advance Directive and Surrogate Process
Penalty
Summary
The facility failed to accurately complete a Physician Orders for Life Sustaining Treatment (POLST) form for a resident with multiple complex medical conditions, including dysphagia, type 2 diabetes mellitus with skin complications, unspecified dementia, psychotic and mood disturbances, anxiety, and tracheostomy status. The resident's electronic health record did not contain an Advanced Health Care Directive (AHCD) appointing a Power of Attorney (POA) for healthcare decisions. Despite this, the POLST form prepared for the resident indicated that his wife was his agent designated in a Power of Attorney for Healthcare, which was not accurate, as confirmed by the social worker and facility records. Further review revealed that the correct designation on the POLST should have been 'Surrogate selected by consensus of interested persons,' as the resident's wife was not his healthcare POA. Additionally, the facility did not have documentation such as a surrogate form or a physician's letter identifying the resident as lacking capacity to make his own healthcare decisions. The social worker confirmed that the facility did not have a process in place for initiating a surrogate decision-maker for residents without capacity, contributing to the inaccurate completion of the POLST form.