Failure to Follow POLST Regarding Artificial Nutrition and Hydration
Penalty
Summary
The facility failed to follow a resident’s advance directive, specifically the Illinois POLST form, regarding the provision of artificial nutrition and hydration. The resident, who had anoxic brain damage, severe protein-calorie malnutrition, acute and chronic respiratory failure, a stage 4 sacral pressure ulcer, tracheostomy and gastrostomy status, and a history of sudden cardiac arrest, was cognitively severely impaired and dependent on staff for all ADLs. The POLST form directed that artificial nutrition and hydration be provided by any means, including new or existing surgically placed tubes. The resident’s care plan documented NPO status with enteral feeding for all nutrition needs, with interventions to adjust tube feeding as needed and monitor tolerance, weight, labs, skin, and hydration. However, record review showed that the resident had no active G-tube feeding orders, only water flushes and medications, and that a prior continuous tube feeding order had been discontinued on a specified date. During observations on two separate days, the resident was seen in bed, unresponsive to questions, with a G-tube plunger at the bedside but no feeding pump or feeding infusing. When questioned, an RN stated she was unsure of the feeding orders and later reported that hospice had discontinued the feeding. The resident’s family member/POA reported being told by hospice that feeding could not be restarted because the resident was at end of life and, lacking clinical experience, accepted this explanation, although she stated she wanted the resident to continue receiving feeding. The DON stated she was unaware that the feeding had been discontinued and affirmed that the facility should follow the POLST. The physician acknowledged knowing that hospice had stopped the feeding due to aspiration risk and that the resident’s wife was said to be okay with it, and further stated that if G-tube feeding is discontinued, the POLST should be readdressed and a new one obtained. The facility’s advance directive/DNR policy states that residents have the right to determine in advance what life-sustaining treatment will be provided, including artificial hydration and nutrition, and that such directions enable staff to know how to treat residents in advance of an emergency.
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