Failure to Timely Update DNR Order in Resident Record
Penalty
Summary
The facility failed to ensure that a do not resuscitate (DNR) order was updated in a timely manner for a resident with multiple complex medical diagnoses, including heart failure, coronary artery disease, hypertension, Parkinson's disease, type 2 diabetes, obesity, schizophrenia, iron deficiency anemia, and hypothyroidism. The resident initially had a physician's order indicating full code status. Subsequently, a State of Indiana Out of Hospital Do Not Resuscitate Declaration and Order form was completed and signed by the resident's representative and a witness, and later by the physician. Despite the completion of the DNR form, there was a delay in updating the physician's order to reflect the resident's new DNR status. Interviews with staff revealed that while the signed DNR form was uploaded into the resident's electronic chart, the corresponding order was not immediately updated to match the form. The Director of Nursing acknowledged that there were instances where the form was uploaded but the orders were not updated accordingly, which led to the deficiency.