Failure to Follow Resident's Plan of Care and POLST Directives
Penalty
Summary
The facility failed to provide care and services consistent with a resident's comprehensive plan of care, resulting in a decline in health status. The resident had diagnoses including diabetes mellitus type II and atrial fibrillation, and had a POLST indicating limited additional interventions, use of IV fluids and cardiac monitoring as indicated, and use of antibiotics if life could be prolonged. Despite these directives, clinical documentation and staff interviews revealed that the contracted on-call provider incorrectly identified the resident as being on comfort care measures, which led to a lack of escalation in care when the resident developed a fever and symptoms suggestive of a urinary tract infection (UTI). Progress notes showed that the resident experienced a fever and foul-smelling urine, and although the on-call provider was notified, documentation stated that only comfort care measures were to be provided, with no escalation of care. This was not consistent with the resident's POLST or physician orders, which did not indicate comfort care status at that time. The resident continued to decline, exhibiting lethargy, poor oral intake, and eventually was found to have a confirmed UTI and acute kidney injury. Orders for antibiotics and IV fluids were eventually given, but only after a significant delay and further deterioration in the resident's condition. Interviews with facility staff, including the DON, confirmed that there was no documentation or order placing the resident on comfort care during the period in question. The failure to follow the resident's established plan of care and advanced directives resulted in delayed and insufficient medical intervention, contributing to the resident's decline and subsequent death.