Inaccurate POLST Documentation for Advance Directive
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure the accuracy of a resident's medical record, specifically regarding the documentation on the resident's Physician Orders for Life-Sustaining Treatment (POLST) form. Review of the medical record revealed that the POLST indicated the resident's advance directive was not available, despite the fact that a Durable Power of Attorney had been uploaded into the electronic medical record prior to the completion of the POLST. During interviews, facility staff confirmed that the POLST should have reflected the presence and review of the advance directive, but this was not accurately documented. This inaccuracy was verified by both the Social Services Director and the Director of Nursing during the survey.