Failure to Honor Existing POLST and Involve Representative in CPR Decision-Making
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident and the resident’s representative were fully informed and involved in decisions regarding cardiopulmonary resuscitation (CPR) and POLST orders. The facility’s policy required staff on admission to determine whether a resident had an advance directive, identify the primary decision-maker, and place a copy of any advance directive, including POLST and DPOA-HC, in the permanent medical record. For one resident with Alzheimer’s dementia, paraplegia/functional quadriplegia, cancer, severe cognitive impairment, and dependence in activities of daily living, hospital records and transfer orders documented an existing POLST indicating Do Not Resuscitate (DNR) and selective medical treatment, as well as a verified medical DPOA-HC designating a collateral contact as the decision-maker. Despite the existing POLST and DPOA-HC, facility staff completed a new POLST with the resident that changed the code status to attempt resuscitation/CPR and full treatment, and the form bore a legible resident signature even though the collateral contact reported the resident could not sign legibly due to quadriplegia. The Resident Care Manager/LPN who reviewed and signed this POLST stated they were likely given a note that the resident needed a POLST and that they typically spoke with residents and, if they seemed "withit," completed the POLST with them. This staff member acknowledged they were unaware that a prior POLST from the hospital had been uploaded into the electronic medical record. The resident’s care plan documented severe cognitive impairment (BIMS score of 7), and speech therapy notes indicated the resident lacked insight into their condition and risk factors and had reduced health literacy. Later, another Resident Care Manager completed yet another POLST with the collateral contact by phone, documenting DNR and selective medical intervention and indicating the discussion was with the POA, with no documentation that the resident was involved. This staff member reported they initiated the new POLST because a medical provider told them the resident did not have a POLST on file and stated they were unaware of the existing POLST. The collateral contact reported attending a care conference where the facility documented CPR full code and that the spouse stated he was POA, and also reported that the facility did not disclose that a new full-code POLST had been completed with the resident. The DNS stated staff were expected to review hospital records on admission, verify any existing POLST and DPOA-HC, assess cognitive status, and involve the resident representative in decision-making when there was an active DPOA-HC and/or cognitive issues, and acknowledged that staff likely did not see or were not aware of the hospital POLST.
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