Failure to Maintain Readily Accessible POLST and Advance Directives in Resident Charts
Penalty
Summary
The facility failed to ensure that Provider Orders for Life-Sustaining Treatment (POLST) and advance directives (AD) were consistently and readily retrievable in the current medical charts for 11 out of 100 sampled residents. This deficiency was identified through observation, interviews, and record reviews, which revealed that staff were unable to locate these critical documents during medical emergencies. In one instance, when a resident was found unresponsive and pulseless, nursing staff could not find the resident's POLST or code status in the current chart and, as a result, initiated CPR by default, treating the resident as full code. The Director of Nursing later found the resident's POLST in an old chart, confirming that the document was still valid at the time of the emergency but had not been placed in the current chart as required by facility policy. Further review of additional residents' records showed similar issues, with several POLST and AD documents missing from current medical charts. Interviews with staff, including nurses and the social worker, confirmed that these documents were either not obtained, not printed, or were kept in locations such as email inboxes or old charts rather than being filed in the residents' current medical records. The facility's policy and procedures, as well as the social worker's job description, require that POLST and AD documents be obtained within 48 to 72 hours of admission and be accessible in the medical record to all facility staff. However, staff interviews revealed a lack of consistent adherence to these procedures, with some staff unaware of whether residents had POLST forms or failing to ensure the documents were properly filed. The deficiency affected residents with a range of medical conditions, including chronic obstructive pulmonary disease, chronic kidney disease, dementia, quadriplegia, and other serious health issues. Many of these residents had impaired or severely impaired cognition and lacked the capacity to make decisions, making the presence and accessibility of POLST and AD documents especially critical. The failure to maintain these documents in the current medical charts was acknowledged by both the Director of Nursing and the social worker, who confirmed that the documents should be readily available in the chart and not stored elsewhere.