F0678

D

Failure to Maintain Accessible and Accurate POLST/Code Status Information During CPR Event

Bellingham, Washington Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that Physician Orders for Life-Sustaining Treatment (POLST) and advance directives were readily accessible and accurately reflected in the electronic medical record (EMR) for use during emergencies. Facility policy required that POLST or advance directive forms be placed in a central, accessible binder on each unit and used to direct care during a code event, with a staff member assigned to obtain the resident’s code status from the binder. The policy also stated that residents have the right to formulate an advance directive and that, during admission, it is determined whether an advance directive is in place and a POLST is offered or assistance provided in completing one. Despite these policies, the facility did not maintain an effective system to ensure that POLSTs were consistently available in binders or accurately documented in the EMR.

Resident 2, who had been admitted from the hospital, had a hospital discharge summary indicating a Do Not Resuscitate (DNR) status and referencing an advance care planning note. On the night of the incident, staff were summoned when Resident 2 was found on the floor, initially warm with a palpable radial pulse, short of breath, and later becoming unresponsive with no pulse. Staff attempted to locate the resident’s code status by checking the POLST binder and the EMR but were unable to find a POLST or any clear code status documentation. The Medication Administration Record directed staff to see a disaster recovery binder for advanced directives and code status, but no POLST for Resident 2 was present in the unit’s POLST book, and there was no documentation in the clinical record that code status had been discussed or that a POLST was in the chart.

During the emergency, 911 was called, and the operator instructed staff to initiate CPR because no POLST could be located. CPR was started by staff and continued until paramedics arrived. While this was occurring, another nurse located information in the hospital discharge paperwork indicating that Resident 2 was DNR and wished for no CPR, at which point CPR was stopped. A collateral contact, the spouse of Resident 2’s roommate, reported that staff had verbally indicated the resident was DNR and that medics repeatedly asked for the POLST, which was reportedly only available online in the hospital file; medics later confirmed the hospital had a DNR on file and then stopped life-saving measures. Review of the second-floor POLST book showed that 23 of 52 residents on the unit had no POLSTs available, and multiple staff interviews confirmed that POLST binders were incomplete, not up to date due to room moves and workload, and that code status was not displayed in the EMR per company policy. Staff also reported that some POLSTs and advance directives were awaiting scanning, were stored in financial folders, or were otherwise not readily accessible to nursing staff, contributing to the inability to promptly verify Resident 2’s code status during the event.

Additional interviews revealed systemic issues in the facility’s process for handling POLSTs and advance directives. Staff described that upon admission, nurses were expected to obtain POLSTs, review them with residents, and then send them for provider signature, after which copies were to be placed in binders and scanned into the EMR. However, staff acknowledged that there were missing POLSTs, a backlog of forms to be scanned, and inconsistent auditing of POLST binders, with some binders not audited for weeks. It was also noted that only certain floors were audited regularly and that some advance directives might be placed in financial folders that nurses would have difficulty accessing. At the time of surveyor observation, POLST binders were located at the reception desk, out of reach of nurses, while they were being audited, further limiting immediate access. These actions and inactions resulted in the facility’s failure to have an accurate, accessible system for code status information, directly affecting the care provided to Resident 2 during a cardiopulmonary emergency.

The report states that this failure to access and follow POLST instructions for CPR or ensure the POLST was readily available for Resident 2 placed residents at risk for receiving unwanted CPR against their known wishes, avoidable trauma, and other negative health outcomes.