Failure to Accurately Reflect POLST Status in Medical Record
Penalty
Summary
The facility failed to ensure that a resident's Practitioner Orders for Life-Sustaining Treatment (POLST) status was accurately reflected throughout the Electronic Health Record (EHR). The resident, who had diagnoses including chronic obstructive pulmonary disease, congestive heart failure, and hypertension, was admitted with an advanced directive indicating Do Not Resuscitate (DNR) status in the admission record and order summary. However, the resident's signed POLST form indicated a preference for full cardiopulmonary resuscitation (CPR) in the event of unresponsiveness. During the survey, the administrator confirmed that the medical record should have matched the resident's POLST wishes for CPR to be performed, but the record incorrectly documented the resident as DNR. The facility's policy requires staff to verify code status using the medical record and to initiate CPR or notify the provider based on that documentation. The discrepancy between the POLST form and the EHR documentation led to the deficiency.