Incomplete POLST Documentation for Incapacitated Resident
Penalty
Summary
The facility failed to complete the Physician Orders for Life-Sustaining Treatments (POLST) for one resident who was admitted with multiple serious medical conditions, including a stage 4 pressure ulcer, urinary tract infection, and a gastrostomy tube. The resident was documented as lacking capacity to make decisions and was assessed as having severely impaired cognitive skills, being totally dependent on staff for daily care. Despite this, the resident's POLST form was found to be incomplete, with critical sections such as Cardiopulmonary Resuscitation, Medical Interventions, Artificially Administered Nutrition, and Information and Signatures left unchecked. The form was also not signed by the resident's legally recognized decision maker, but only by the provider. During interviews, staff confirmed that the POLST was incomplete and acknowledged that all sections should be filled out as it is a legal document reflecting the resident's care preferences in emergencies. The facility's policy required that the provider speak with the resident or their legal representative to ensure the POLST accurately reflected the resident's wishes before signing. However, this process was not followed, and the responsibility for ensuring the POLST was complete was not met by the social worker and licensed nursing staff, as stated by the Director of Nursing.