Failure to Ensure Proper Completion of POLST for Resident Lacking Capacity
Penalty
Summary
The facility failed to ensure that the Physician Orders for Life Sustaining Treatment (POLST) form was appropriately completed for a resident with severe cognitive impairment. The resident, who had a BIMS score of 00 indicating severe decision-making impairment, was admitted with diagnoses including dementia, diabetes type 2, and dysphagia. Despite the resident's lack of capacity, as documented in the Minimum Data Set (MDS), the POLST form was signed by the resident rather than the legally recognized decisionmaker, contrary to facility policy and professional standards. Interviews with the Director of Nursing (DON) and Social Services Director confirmed that the POLST should have been signed by the resident's legal representative, not the resident, due to the resident's incapacity. The facility's policy explicitly states that the form must be signed by the resident with capacity or by the resident representative when the resident lacks capacity. The DON acknowledged that the policy was not followed in this instance, and the documentation review supported this finding.