Failure to Send Current POLST Form During Resident Transfer
Penalty
Summary
The facility failed to provide the most current Provider Order for Life Sustaining Treatment (POLST) form to the receiving provider when a resident was transferred to the emergency department. The resident's POLST specified Do Not Resuscitate (DNR) status, comfort-focused treatment, no artificial nutrition by tube, and no antibiotics, with a preference for no hospital transfer unless comfort needs could not be met at the facility. Despite these clear directives, the POLST was not sent with the resident during the transfer to the hospital. Interviews with facility staff revealed that the standard process for emergency transfers included sending the face sheet, order summary, medication administration record, and the current POLST form with the resident. However, the LPN responsible for the transfer did not print or send the POLST, and the care coordinator who initiated the process left the building before the transfer was completed, also not ensuring the POLST was included. As a result, the hospital only had access to an outdated POLST, which led to confusion regarding the resident's wishes, particularly concerning the administration of antibiotics. The resident had a history of moderately impaired cognition, paranoid schizophrenia, intellectual disabilities, and diabetes. Upon admission to the hospital, the absence of the current POLST led to a review of an older version, which did not reflect the resident's most recent preferences. This discrepancy was only clarified after discussions with the resident's family and review of the available documentation, but the initial failure to send the correct POLST form resulted in a lack of immediate clarity regarding the resident's treatment preferences during the hospital stay.