F0578

E

Incomplete and Inconsistent Advance Directives and POLST Documentation

Dolton, Illinois Survey Completed on 07-31-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that advance directives and Physician Orders for Life-Sustaining Treatment (POLST) forms were accurately completed and consistently maintained for multiple residents, resulting in discrepancies between documented wishes and the information available to guide care. One resident, R17, had an advance directive in the electronic record signed on a specified date, but the form contained no selection for the type of treatment, leaving staff without clear direction in an emergency. When this was presented to the DON, she acknowledged that there should be an indication of the type of treatment required and that completed advance directives should be uploaded into the medical record.

Additional findings showed multiple problems with POLST forms for other residents. R55’s undated POLST documented a selection for “Attempt Resuscitation/CPR,” which per the form means “Full Treatment” in Section B, but Section B was instead marked for “Selective Treatment,” creating an internal inconsistency on the same form. The undated POLST forms for R69 and R145, and the dated POLST form for R92, were all signed by both the resident and the physician but contained no selections in Sections A, B, C, or D. The Social Services Director acknowledged that R55’s POLST was not documented correctly and stated that the forms should be filled out completely, and that if POLST forms are not completed and completed correctly, the hospital and the facility would not know what to do. These practices were inconsistent with the facility’s own Advance Directives policy, which requires that advance directives be copied and maintained in the medical record, reviewed by the interdisciplinary team, and used to guide orders and documentation regarding life-sustaining measures.