Inaccurate POLST Form Fails to Reflect Resident's Code Status
Penalty
Summary
A deficiency was identified when the facility failed to ensure that a resident's Physician Orders for Life Sustaining Treatment (POLST) form accurately reflected the resident's code status as documented in the physician's order. The resident, who had diagnoses of senile degeneration of the brain and chronic obstructive pulmonary disease, was admitted with specific physician orders indicating Do Not Resuscitate (DNR), Do Not Hospitalize (DNH), and Do Not Intubate (DNI) status. However, upon review, the POLST form for this resident was found to indicate CPR/Attempt Resuscitation, which was inconsistent with the physician's documented orders in the electronic medical record. This discrepancy was confirmed during an interview with the Director of Nursing, who acknowledged that the POLST form did not match the resident's code status as ordered by the physician. The failure to ensure consistency between the physician's orders and the POLST form constituted a violation of resident care policies and nursing services regulations.