Failure to Honor DNR Order and Complete POLST During Medical Emergency
Penalty
Summary
The facility failed to ensure that a Physician's Orders for Life Sustaining Treatment (POLST) was completed and that an existing Do Not Resuscitate (DNR) physician order was followed for one resident during a medical emergency. The resident, who was self-responsible and had documented capacity to make medical decisions, had an active DNR order in place. During a medical emergency, the resident was found unresponsive, with no vital signs, and CPR was initiated by a registered nurse. Emergency responders arrived and used a defibrillator, successfully obtaining a pulse before suspending CPR. The emergency team was informed of the DNR order but noted that no POLST was on file, and the facility was asked to contact the family to clarify the code status. Record review and staff interviews confirmed that although the resident had a DNR order, there was no completed POLST form in the resident's file. The facility's policy required that DNR orders be honored and specified that no resuscitative measures should be used when such orders are in effect. Despite this, CPR and defibrillation were performed. Documentation showed that the resident's wishes regarding resuscitation had been discussed and verbally consented to, but the required POLST form was not completed or available at the time of the emergency.