Incomplete DNR Documentation for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to ensure that a resident's advance directive, specifically a Do Not Resuscitate (DNR) order, was thoroughly completed and valid. The resident in question had diagnoses of dementia, depression, and anxiety, with severely impaired cognition as documented by low BIMS scores on multiple Minimum Data Set (MDS) assessments. The resident was dependent on staff for all activities of daily living and was receiving hospice services. The resident's care plan and physician orders documented a DNR, but the only DNR form available in the electronic health record was a hospice-based form signed solely by the physician, lacking the required signature from the resident or the resident's representative. Interviews with facility staff confirmed that the DNR form in the record was incomplete and not valid, as it did not include the necessary signature from the resident or their durable power of attorney (DPOA), nor was it witnessed. The facility was unable to provide a policy for advance directives. This incomplete documentation resulted in the resident's advance directive not being properly honored according to regulatory requirements.