Failure to Verify and Document Resident's DNR Directive
Penalty
Summary
The facility failed to verify and properly document a resident's advanced directives, specifically regarding a Do-Not-Resuscitate (DNR) order. The resident, who had diagnoses including Parkinson's disease, atherosclerotic heart disease, epilepsy, heart failure, and hypertension, was documented as having intact cognition and had recently started hospice care with a terminal diagnosis. The care plan indicated the resident wished to remain a DNR, but a review of the electronic health record (EHR) revealed inconsistencies: the hospice certificate listed the resident as full code, while the EHR home screen and physician orders listed the resident as DNR. The DNR directive in the EHR was signed by the physician but not by the resident or their representative, as required. Interviews with the resident confirmed her wish to be a DNR, and staff acknowledged the missing resident signature on the DNR directive. Staff also indicated that, in the event of discrepancies between DNR and full code orders, the most recent advanced directive should be honored. However, the facility did not provide a policy for advanced directives, and the lack of a resident signature on the DNR directive represented a failure to ensure the resident's wishes were properly documented and verified.