Failure to Implement POLST and Provide Post-ER Comfort-Focused Assessment and Care
Penalty
Summary
The deficiency involves the facility’s failure to implement a resident’s Physician Orders for Life-Sustaining Treatment (POLST) and provide appropriate assessment and comfort-focused care upon return from the emergency room. The resident, who was his own responsible party, had a POLST dated 10/16/2018 indicating Do Not Attempt Resuscitation and comfort-focused treatment, including relief of pain and suffering with medications, and use of oxygen, suctioning, and manual treatment of airway obstruction as needed. His medical history included acute respiratory failure with hypoxia and dysphagia, and a speech therapy discharge summary specified a soft and bite-sized diet with mildly thick liquids and general swallow precautions with upright posture during meals. The care plan for acute respiratory failure with hypoxia, initiated 10/13/24, directed staff to maintain a clear airway and suction as needed if secretions could not be cleared. On 12/22/25, an SBAR form documented that the resident had shortness of breath, a respiratory rate of 30 breaths per minute, and an oxygen saturation of 62%, after which a nurse practitioner was notified and recommended transfer to the ER. ER documentation showed the resident arrived at 3 a.m. with abnormal vital signs, including tachycardia, hypotension, tachypnea, and an O2 saturation of 95% on a non-rebreather mask, and was described as ill-appearing, unresponsive to tactile stimulation, with rhonchi present. ER notes stated that no further treatment would be provided due to his DNR and comfort care status and that he was comfortable and appropriate for return to the facility, and he was discharged back at 5:19 a.m. Upon his return, there was no documented nursing evaluation, including no vital signs, no assessment of respiratory status, no documentation of comfort measures such as suctioning, and no evaluation of level of consciousness. During interview and record review, the DON confirmed the absence of documented assessments and implementation of comfort measures per the POLST and stated her expectation that licensed nurses perform vital signs, assess, treat symptoms, follow physician orders, and document timely. The facility’s POLST policy required updating the plan of care and ongoing reassessment when a resident exhibits a sudden or marked adverse change, which was not reflected in the documentation for this resident.
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