Incomplete Advance Directive Documentation for DNRCC
Penalty
Summary
A deficiency was identified when a resident's advance directive form, specifically the DNR Comfort Care (DNRCC) document, was found to be incomplete. The form was signed by the physician but lacked a date, and required sections under 'Certification of DNR Comfort Care Status' were left blank. These sections included options for 'Do-Not-Resuscitate-Order' or 'Living Will (Declaration) and Qualifying Condition,' with instructions to select only one, but neither was marked. The deficiency was confirmed through medical record review and staff interview. The resident involved had multiple significant diagnoses, including chronic obstructive pulmonary disease, end stage renal disease, heart failure, and dysphagia, and was dependent on staff for all activities of daily living due to impaired cognition. Despite an active physician order for DNRCC, the incomplete documentation on the advance directive form was verified by an LPN, who acknowledged that the physician's date and proper selections were required but missing.