Inconsistent and Incomplete POLST Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that physician orders and residents' Pennsylvania Orders for Life Sustaining Treatment (POLST) were consistent and complete for two residents. For one resident with diagnoses including diabetes, dementia, and chronic obstructive pulmonary disease, the paper clinical record contained a POLST indicating Full Code status, while the physician's order in the electronic record indicated Do Not Attempt Resuscitation (DNR). Additionally, a second POLST in the clinical record indicated DNR but lacked the required signature from the resident or their representative. For another resident with hypertension, hyperlipidemia, and hypothyroidism, the POLST was incomplete, with the section indicating Full Code or DNR status left blank. Staff interviews revealed that during emergencies, staff refer to the paper chart to determine residents' life-sustaining treatment preferences. The DON confirmed the inconsistencies between the paper and electronic records and acknowledged that advance directives should be complete and consistent across all records, clearly indicating the resident or representative's wishes. The facility's policy requires that information about advance directives be prominently displayed and that appropriate orders be documented, which was not followed in these cases.