Failure to Document Advance Directive and POLST Status
Penalty
Summary
A deficiency occurred when a resident was documented as full code in their medical record without having a completed Physician Orders for Life-Sustaining Treatment (POLST) or Advance Directive on file. The resident, who had multiple significant diagnoses including acute respiratory failure with hypoxia, chest pain, pleural effusion, COPD, asthma, atrial fibrillation, type 2 diabetes with complications, secondary hypertension, and shortness of breath, was admitted and readmitted to the facility. Despite the facility's policy requiring determination and documentation of advance directives upon admission, the resident's medical record lacked both a POLST and an Advance Directive, and the POLST status was left blank in the admission progress note. Interviews with the DON and Administrator confirmed that the required POLST form could not be located in the resident's record. The DON stated that completed POLST forms are to be turned in to her and then given to the Medical Director for signature, with monthly audits by the Resident Advocate. However, for this resident, the process was not completed as required, resulting in the absence of critical documentation regarding the resident's code status and advance directive preferences.