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F0578
E

Inconsistent Physician Orders with Residents' POLST Code Status

Shenandoah, Pennsylvania Survey Completed on 07-02-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

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