Inconsistent Physician Orders and POLST Forms for Life-Sustaining Treatment
Penalty
Summary
The facility failed to ensure that physician orders and Physician Order for Life Sustaining Treatment (POLST) forms were consistent for two residents. According to facility policy, documentation of informed consent to withhold or withdraw treatment must be placed in the resident's clinical record, along with the attending physician's order, and this information should be reflected in the resident's plan of care. For one resident with diagnoses including anxiety, hyperlipidemia, and hypertension, the physician's order indicated cardiopulmonary resuscitation (CPR), while the POLST form indicated Do Not Resuscitate-Allow Natural Death (DNR). For another resident with heart failure, hypertension, and muscle weakness, the physician's order indicated DNR, but the POLST form indicated CPR. These inconsistencies were confirmed during an interview with the Director of Nursing, who acknowledged that the physician orders and POLST forms for the two residents did not match. The deficiency was identified through review of facility policy, clinical records, and staff interviews, and it was determined that the facility did not honor the residents' rights to have their treatment preferences accurately documented and followed as required by state regulations.