Failure to Accurately Document and Implement DNR Order
Penalty
Summary
A deficiency was identified when the facility failed to ensure consistent implementation and documentation of a Do Not Resuscitate (DNR) order for a resident with dementia and a malignant neoplasm of the prostate. The resident, who had moderate cognitive impairment as indicated by a BIMS score of 12, had a DNR order signed by both the resident and their physician. However, the electronic medical record (EMR) demographic page incorrectly listed the resident as "Full code," meaning cardiopulmonary resuscitation (CPR) would be performed in the event of cardiac arrest. During interviews, both a nurse and a social worker reviewed the resident's EMR and initially reported the resident as "Full code." It was only after further review that the social worker discovered the signed DNR order in the record and acknowledged the discrepancy. The social worker was unaware of how the error occurred and indicated the need for correction to reflect the resident's actual wishes as documented in the DNR order. Facility policy requires that a fully executed DNR form be uploaded into the resident's electronic health record and that the physician's order for DNR be entered so the code status is accurately displayed in the chart header and face sheet. In this case, despite the presence of a valid DNR order, the resident's code status was not accurately reflected in the EMR, leading to confusion among staff regarding the resident's end-of-life care preferences.
Plan Of Correction
578 Request/Refuse/Discontinue treatment; Formulate Adv Dir It is the practice of the facility to ensure the resident right to request, refuse and/or discontinue treatment, to participate in or refuse to participate in experimental research and to formulate an advance directive. Element 1 Resident 408 remains in the facility and has been unharmed by the deficient practice. The resident's code status order has been corrected to DNR (do not resuscitate). Element 2 Residents residing in the facility who have signed a DNR are at risk. An audit was completed by the DON/designee of all residents with a signed DNR to ensure their physician order and demographics page match. The plan of care has been reviewed and updated by the interdisciplinary team. Element 3 The interdisciplinary team reviewed the advanced directive policy and deemed it appropriate for use as written. The licensed nursing staff and social work staff were educated on the policy. Element 4 The administrator/designee will audit all new admits/readmits to ensure appropriate advance directives orders and documentation is in place weekly x4 and monthly x3. Element 5 The administrator/designee holds the ultimate responsibility of compliance: date of compliance May 6, 2025.