Failure to Accurately Transcribe and Reflect POLST Orders in EMR
Penalty
Summary
The facility failed to ensure that written Physician's Orders for Life Sustaining Treatment (POLST) were accurately entered, transcribed, and reflected in the electronic medical record (EMR) in a timely manner, resulting in discrepancies between residents' documented wishes and the code status available to staff during emergencies. For two residents reviewed for advanced directives, the POLST forms indicated Do Not Resuscitate (DNR) status, but the EMR and Medication Administration Record (MAR) listed them as Full Code. Staff interviews revealed that nurses relied on the MAR or EMR banner for code status information and would have initiated CPR based on the incorrect Full Code status, contrary to the residents' documented wishes for DNR. One resident, who had multiple complex medical conditions including heart failure, renal insufficiency, and diabetes, had a POLST form signed by both the resident and the provider indicating DNR status. However, the EMR and MAR continued to display Full Code, and staff were unaware of the discrepancy. Multiple nurses confirmed they would have performed CPR based on the MAR instructions. The process for updating code status in the EMR relied on the health unit coordinator (HUC), but there was no consistent double-check or audit process in place to ensure accuracy. The facility's policy did not specify where staff should verify the most current code status in an emergency, contributing to the confusion. A second resident also had a signed POLST indicating DNR, but the EMR banner still listed Full Code. Staff interviews confirmed that in an emergency, they would have followed the EMR banner and initiated CPR. There was also a delay in obtaining provider signatures on POLST forms, during which time the residents' wishes were not reflected in the active orders. The lack of timely transcription and verification of POLST information into the EMR and MAR, as well as unclear procedures for staff to verify code status, led to the deficiency.