Failure to Ensure Proper Completion of DNR Documentation
Penalty
Summary
The facility failed to ensure that a resident's Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) form was properly completed, specifically lacking the required physician's signature. The resident in question had a documented history of metabolic encephalopathy, unspecified dementia, muscle weakness, and bipolar disorder, and was admitted with a code status of DNR. The resident's care plan and physician orders reflected a DNR status, and the OOH-DNR form was signed by the resident's spouse but not by the attending physician, as required by both facility policy and state law. Interviews with facility staff revealed a breakdown in the process for obtaining and verifying the necessary physician signature on the DNR form. The social services staff provided the form to the resident or family and obtained their signatures, then forwarded the form to medical records for physician signature. However, the form was uploaded into the electronic medical record system without the physician's signature, and staff did not recall why this incomplete form was uploaded. The medical records staff confirmed that the physician's signature was only obtained after the surveyor's inquiry, despite the form being received the previous year. Further interviews with nursing and administrative staff indicated confusion and inconsistency regarding when a resident's DNR status should be updated in the electronic record system. Some staff believed that a DNR status in the system indicated a completed and valid DNR, while others acknowledged that without the physician's signature, the DNR was not legally valid. The facility's policy and state requirements both specify that the physician's signature is necessary for the DNR to be honored, but this step was not completed in a timely manner for the resident in question.