Failure to Obtain Valid POLST and Determine Code Status Delays Life-Sustaining Treatment
Penalty
Summary
The facility failed to obtain a credible Physician Orders for Life-Sustaining Treatment (POLST) for a resident who was capable of signing her own consent. Instead, the POLST was signed by a family member who was only designated as the resident's emergency contact and served as an interpreter, not as the responsible party. The POLST indicated a Do Not Resuscitate (DNR) order and comfort-focused treatment, but the resident's own wishes were not directly documented due to this procedural error. During a medical emergency, staff were unable to determine the resident's code status promptly. Instead of having clear documentation, staff inquired with two family members at the bedside and by phone about whether to initiate CPR. This led to confusion and a delay in starting life-sustaining procedures. Interviews with staff and family confirmed that the family member who signed the POLST was not authorized to make such decisions, and that staff routinely contacted families during emergencies to confirm or change code status, contrary to established policy and the resident's rights. The resident, who had diagnoses including type 2 diabetes, generalized muscle weakness, and anxiety disorder, was noted to have moderately impaired cognition but was still capable of making her own decisions. During the emergency, CPR was not initiated until after family consultation, despite the presence of a DNR order signed by an unauthorized party. Paramedics eventually performed CPR upon arrival, but the resident expired at the facility. Facility policy and state law require that POLST forms reflect the patient's preferences and be followed by healthcare providers.