Failure to Maintain Valid POLST Resulting in Conflicting Code Status Information
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records by not obtaining a physician’s signature on a resident’s updated Physician Orders for Life-Sustaining Treatment (POLST) form. The resident, an older female with multiple serious diagnoses including fracture of the left humerus, acute and chronic respiratory failure with hypoxia, interstitial pulmonary disease, pneumonia, and chronic kidney disease with hypertensive heart disease and heart failure, had two POLST forms on file. One POLST dated 10/05/2023 indicated DNR, selective treatment, and a trial period of artificial nutrition and was signed by a physician on 10/06/2023. A subsequent POLST dated 10/25/2024 indicated DNR, selective treatment, and no artificial means of nutrition, but this form lacked a physician’s signature. The facility’s Order Summary Report still reflected an active order for DNR, selective treatment, and no artificial means of nutrition, consistent with the unsigned 2024 POLST. On the day of the incident, progress notes documented that the resident was eating breakfast with assistance and tolerating a few bites and sips of juice before being found unresponsive around 8:15–8:20 a.m., prompting a 911 call. When EMS arrived, they found the resident pulseless and apneic, and staff provided conflicting information about the resident’s status. EMS noted there were two DNR forms, both marked DNR, but the most recent form was not signed, creating uncertainty about which POLST to follow. Basic Life Support was initiated due to this uncertainty, and the facility contacted the resident’s daughter, who requested full resuscitation measures. During interview, the DON acknowledged that there were two POLST forms, that EMS expressed confusion regarding which to follow, and that the updated POLST on readmission had been overlooked for physician signature, despite facility policy requiring POLST documents to be reviewed for validity and signed by the physician and the resident or legal decision-maker.
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