Inconsistent Advance Directive and POLST Documentation
Penalty
Summary
The facility failed to ensure that a resident's physician orders and Pennsylvania Order for Life Sustaining Treatment (POLST) were consistent, as required by facility policy and state regulations. The resident in question had multiple documents in their clinical record, including a Living Will indicating Do Not Resuscitate (DNR) status and a POLST indicating Full Code status. Physician orders in the record were conflicting, with some indicating Full Code and others indicating DNR. Progress notes from both social services and nursing documented changes in the resident's code status, but the most recent POLST available in the unit binder and on the nurse report sheet still indicated Full Code, while physician orders indicated DNR. Interviews with an LPN confirmed that the documentation in the binder and on the nurse report sheet did not match the most current physician orders. The LPN acknowledged that the most recent POLST, signed by the resident and physician, indicated Full Code, while the physician's orders indicated DNR. This inconsistency between the resident's advance directives, POLST, and physician orders resulted in a failure to honor the resident's documented treatment preferences as required by policy.