Inconsistent Physician Orders with Residents' POLST Code Status
Penalty
Summary
The facility failed to ensure that physician orders accurately reflected the residents' elected code status as documented in their most current, signed POLST forms for two residents. For one resident with dementia and diabetes, the physician order in the electronic health record indicated Full Code status, while the signed POLST indicated DNR status. This inconsistency was only corrected after surveyor inquiry, when a physician order for DNR was entered. Similarly, another resident with dementia and urine retention had a physician order indicating DNR status, while the signed POLST indicated the resident elected CPR and resuscitation. This discrepancy was also addressed only after surveyor questions, with a subsequent physician order for Full Code. The Regional Nurse Consultant confirmed that the physician orders did not align with the most current, signed POLST forms for these two residents.