Incomplete DNR Form Due to Missing Date
Penalty
Summary
The facility failed to fully complete a Do Not Resuscitate (DNR) form for a resident with diagnoses including hypertension and cognitive impairment. Upon review, the resident's DNR form was found to be signed by the Nurse Practitioner (NP) but was missing the required date. The electronic medical record did contain a physician's order for DNR with a date, but the paper DNR form itself was incomplete. Interviews with staff revealed that the process for completing DNR forms involves the admissions nurse filling out the form, which is then to be signed and dated by the NP before being scanned into the electronic record and stored in a binder at the nurse's station. Both the Unit Manager and DON confirmed that the DNR form should be dated and checked during the 24-hour chart review after admission. The NP stated that forms are typically dated before she signs them, but in this instance, the date was missing. The Administrator acknowledged that the NP was responsible for both signing and dating the form and noted that the NP was new to the process.