Powder River Manor: Missing Doctor Signatures - MT
Powder River Manor failed to ensure a completed POLST form was properly signed and accessible for resident #5, according to a September complaint inspection. The Physician Orders for Life-Sustaining Treatment form indicated "No CPR" and "selective treatment" but lacked the required physician signature, date, and printed provider name.
The form had been filled out by the resident's responsible party, who also failed to sign it.
POLST forms serve as portable medical orders that tell emergency personnel exactly what treatments a patient wants during a medical emergency. Without proper signatures, the orders cannot be legally followed.
Staff member F told inspectors during an interview that admission forms, including POLST documents, were typically reviewed by staff, residents, responsible parties, and family members. Some forms were given to residents or responsible parties to complete ahead of time before entering the facility.
When asked why resident #5's POLST remained incomplete, staff member F said she wasn't sure.
The facility's own policy defines POLST forms as designed "to improve patient care by creating a portable medical order form that records patients treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency."
Montana requires that POLST forms be signed by a licensed physician, advanced practice registered nurse, or physician assistant to be valid. The patient or legal decision-maker must also sign for the orders to take effect.
The incomplete documentation creates a dangerous gap in emergency care. Without valid physician orders, emergency responders cannot honor a resident's wishes to refuse CPR or limit aggressive treatments. They would be required to perform full resuscitation measures regardless of the family's stated preferences.
Federal nursing home regulations require facilities to honor residents' rights to request, refuse, or discontinue treatment and to formulate advance directives. The missing signatures directly violate these protections.
The inspection found the incomplete POLST in both the resident's hard chart and electronic medical record, meaning staff had multiple opportunities to identify and correct the missing information.
Facility documents show Powder River Manor has established procedures for advance care planning, defined as "a process of communication between individuals and their healthcare agents to understand, reflect on, discuss, and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions."
But the procedures weren't followed for resident #5.
The violation affected one of five residents whose records were reviewed during the inspection. Inspectors classified the harm level as minimal, though the potential consequences could be severe during an actual medical emergency.
Staff member F's uncertainty about why the form remained incomplete suggests systemic problems with the facility's admission process and oversight of critical medical documentation.
The case highlights broader challenges nursing homes face in managing complex end-of-life paperwork. POLST forms require coordination between families, facility staff, and outside physicians who may not be familiar with the admission process timeline.
However, the facility's own policy acknowledges the critical importance of these documents. The forms must be readily accessible to ensure emergency personnel can quickly determine a resident's treatment preferences during crisis situations.
Montana's POLST program aims to ensure patients' wishes are honored across different care settings. The forms are designed to travel with patients from nursing homes to hospitals to emergency scenes.
When properly completed, POLST forms provide clear, legally binding instructions that prevent unwanted medical interventions while ensuring desired treatments are provided.
The September inspection was conducted in response to a complaint, though the specific nature of the complaint was not detailed in the report. Federal inspectors found the facility failed to meet basic requirements for advance directive documentation.
Powder River Manor's violation demonstrates how administrative failures can undermine residents' fundamental rights to control their own medical care, even when families have attempted to document their wishes.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Powder River Manor from 2025-09-10 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
POWDER RIVER MANOR in BROADUS, MT was cited for violations during a health inspection on September 10, 2025.
Powder River Manor failed to ensure a completed POLST form was properly signed and accessible for resident #5, according to a September complaint inspection.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.