Failure to Obtain Physician Signature on OOH-DNR Form
Penalty
Summary
The facility failed to ensure that a resident's Out of Hospital Do Not Resuscitate (OOH-DNR) order was properly completed and valid. Specifically, the OOH-DNR form for a female resident with a history of wedge compression fracture, hypertension, and chronic obstructive pulmonary disease was not signed by the attending physician, leaving the document invalid. The resident and two witnesses had signed the form, but the required physician's signature was missing in both the physician's statement section and the acknowledgment section. The resident's care plan and order summary indicated DNR status, and staff interviews confirmed awareness of the resident's wishes, but the necessary physician signature was not obtained at the time of review. Staff interviews revealed that the OOH-DNR form was pending the physician's signature and that the facility routinely uploaded DNR forms into the electronic health record while awaiting this signature. Despite a verbal DNR order from the physician and the facility's intention to honor the resident's wishes, the lack of a physician's signature on the OOH-DNR form meant the document was not legally valid. Review of state guidelines confirmed that only the attending physician could sign the form and that all required signatures must be present for the document to be honored by health professionals.