Mismatch Between POLST Orders and Documented Advanced Directives
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents’ electronic medical records (EMR), care plans, and physician order sheets accurately reflected and matched their completed Physician’s Orders for Life-Sustaining Treatment (POLST) forms for scope of treatment. The facility’s Advance Directives policy requires that when a resident has an advance directive regarding CPR or scope of treatment (POLST), appropriate forms are completed, a specific physician order is obtained for each directive, and the directives are included in the resident’s plan of care. For four residents reviewed for advance directives, the EMR face sheets and physician order sheets documented only a Do Not Resuscitate (DNR) status and did not incorporate the additional treatment preferences specified on their POLST forms. For one resident, the EMR face sheet and physician order sheet listed “Advanced Directives: DNR,” and the care plan documented that the resident had signed a valid DNR and instructed staff not to resuscitate if there was no breathing or pulse. However, the resident’s POLST, signed by the resident, also directed that if not in cardiac arrest and with a pulse, staff should follow “Selective Treatment,” including limited medical measures such as non-invasive positive airway pressure (CPAP/BiPAP), IV fluids, antibiotics, vasopressors, antiarrhythmics, and hospital transfer if indicated. These additional scope-of-treatment instructions were not reflected in the care plan, EMR face sheet, or physician order sheet. Similarly, three other residents had EMR face sheets and physician order sheets that documented only DNR status, and their care plans addressed only the DNR directive. Their signed POLST forms, however, contained more detailed instructions for care when not in cardiac arrest, including “Selective Treatment” or “Limited Additional Interventions,” specifying use of medical treatments such as antibiotics, IV fluids, cardiac monitoring, non-invasive airway support, hospital transfer with general avoidance of ICU, and, for one resident, a defined six-month trial of artificial nutrition by tube. These POLST directives were not incorporated into the residents’ care plans or reflected on the EMR face sheets and physician order sheets. In interviews, an LPN stated that nurses rely on the EMR status board/face sheet to determine advanced directives in an emergent situation, and the Administrator and Interim DON confirmed that POLST instructions should be reflected in the EMR and care plans and that these documents should match the residents’ wishes.
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