Failure to Maintain and Provide DNR POLST and Hospice Documentation
Penalty
Summary
The facility failed to ensure that a physician’s order for life-sustaining treatment (POLST) and required hospice documentation were obtained, maintained on-site, and made available to emergency personnel for a hospice resident with metastatic lung cancer. The resident was initially admitted as full code with a POLST indicating full resuscitation, later hospitalized for acute on chronic hypoxic respiratory failure, and then returned under hospice care. A hospice policy and hospice agreement required the facility to maintain the most recent care plan including advance directives, the hospice election form, physician certification of terminal illness, and other hospice orders. However, review of the hospice binder and medical record showed that the hospice election form, physician certification of terminal illness, and advanced directives including a DNR POLST reflecting the resident’s DNR status were missing. The DON confirmed that the hospice DNR election form alone was not an acceptable substitute in the state because it lacked a physician’s order. On the day of the incident, the RN found the hospice resident unresponsive but with vital signs during morning rounds and contacted hospice and the family. The RN reported that there was no DNR POLST in the hospice binder and hospice could only provide a DNR election form, which took time to be received and did not have a physician’s signature. During this period, the family panicked over the resident’s unresponsive state, began chest compressions, and another family member called 911. When emergency medical services arrived, they requested hospice documents and the DNR POLST, but the facility was unable to provide them, and the resident was transported to the hospital. Surveyors determined that the lack of a DNR POLST and other required hospice paperwork in the facility, contrary to facility policy and the hospice agreement, resulted in confusion among staff and emergency personnel and placed hospice residents at risk for advance directives not being honored at end of life.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.