Incomplete POLST Documentation for Incapacitated Resident
Penalty
Summary
A deficiency occurred when the facility failed to complete the Physician Orders for Life-Sustaining Treatment (POLST) for a resident who was admitted with multiple complex medical conditions, including a stage 4 pressure ulcer, urinary tract infection, and a gastrostomy tube. The resident was determined to lack capacity to make medical decisions, as documented in both the History and Physical and the Minimum Data Set, which indicated severely impaired cognitive skills and total dependence on staff for daily activities. Upon review, the resident's POLST form was found to be incomplete. Key sections of the form, including those addressing cardiopulmonary resuscitation, medical interventions, artificially administered nutrition, and the information and signatures section, were not filled out. The form was signed only by the provider and not by the resident's legally recognized decision maker, as required when the resident lacks capacity. The responsible registered nurse confirmed that the POLST should not have been signed by the provider alone and that all sections must be completed for the document to be valid. The Director of Nursing stated that it was the responsibility of the social worker and licensed nursing staff to ensure the POLST was fully completed. Facility policy also required that the provider confirm the orders with the resident or, if incapacitated, the legally recognized decision maker before signing. The failure to complete the POLST as required resulted in the resident's medical wishes not being properly documented or available to guide care in the event of an emergency.
Plan Of Correction
F-578 Corrective Action On 9/8/25, the Director of Nursing (DON) gave the Social Service Designee (SSD) an inservice about the facility's policy on advanced directive and POLST. Reviewed the process in completing the Advanced Directive and POLST accurately and timely to avoid delay in treatment or life-sustaining procedures in the event of an emergency. On 9/8/25 and 9/11/25, the DON gave the Licensed Nurses an inservice about the facility's policy on advanced directive and POLST. Reviewed the process in completing the Advanced Directive and POLST accurately and timely to avoid delay in treatment or life-sustaining procedures in the event of an emergency. Identification of Others On 9/11/25, the DON and Medical Records Director reviewed all the other charts to review the resident's POLST. No other resident received the deficient practice. Measures to Prevent Recurrence On 9/8/25, the DON gave the SSD an inservice about the facility's policy on advanced directive and POLST. Reviewed the process in completing the Advanced Directive and POLST accurately and timely to avoid delay in treatment or life-sustaining procedures in the event of an emergency. On 9/8/25 and 9/11/25, the DON and/or gave the Licensed Nurses an inservice about the facility's policy on advanced directive and POLST. Reviewed the process in completing the Advanced Directive and POLST accurately and timely to avoid delay in treatment or life-sustaining procedures in the event of an emergency. The DON and/or designee will repeat the inservices every month for 3 months and then as needed to ensure compliance. Monitoring Performance Starting 9/11/25, the Medical Records Director and/or designee will review 5 random charts and review if the POLST is complete; weekly x 4 weeks. The Administrator, and the DON will present the recapitulations of the findings to the monthly QAPI for review and action as indicated. Identification of Others On 9/11/25, the DON and Medical Records Director reviewed all the other charts to review the resident's POLST. No other resident received the deficient practice. Measures to Prevent Recurrence On 9/8/25, the DON gave the SSD an inservice about the facility's policy on advanced directive and POLST. Reviewed the process in completing the Advanced Directive and POLST accurately and timely to avoid delay in treatment or life-sustaining procedures in the event of an emergency. On 9/8/25 and 9/11/25, the DON and/or gave the Licensed Nurses an inservice about the facility's policy on advanced directive and POLST. Reviewed the process in completing the Advanced Directive and POLST accurately and timely to avoid delay in treatment or life-sustaining procedures in the event of an emergency. The DON and/or designee will repeat the inservices every month for 3 months and then as needed to ensure compliance. Monitoring Performance Starting 9/11/25, the Medical Records Director and/or designee will review 5 random charts and review if the POLST is complete; weekly x 4 weeks. The Administrator, and the DON will present the recapitulations of the findings to the monthly QAPI for review and action as indicated.