Failure to Update POLST to Reflect Resident's Current Wishes and Treatment
Penalty
Summary
The facility failed to ensure that a Provider Order for Life Sustaining Treatment (POLST) was updated to accurately reflect the current wishes of a resident with severely impaired cognition, quadriplegia, and chronic respiratory failure. The resident had a tracheostomy and required mechanical ventilation, yet the POLST form indicated Do Not Resuscitate (DNR) with selective treatment, specifying no intubation, advanced airway, or mechanical ventilation. This conflicted with the resident's actual care needs, as the resident was dependent on mechanical ventilation following a recent hospitalization. The provider order and POLST were not aligned with the resident's current treatment, and the POLST had not been updated after significant changes in the resident's condition. Interviews with nursing staff revealed uncertainty about the frequency of POLST reviews after admission, and it was confirmed that while care conferences discussed the POLST, the actual form was not reviewed for accuracy. The Director of Nursing stated that POLST forms should be reviewed upon admission and after hospitalizations, but this was not consistently done. Facility policy required routine audits of POLST documentation, but this was not followed, resulting in a discrepancy between the resident's documented wishes and the care provided.