Incomplete DNR Form Results in Invalid Advance Directive
Penalty
Summary
The facility failed to completely fill out a Durable Do Not Resuscitate (DNR) form for one resident. The DNR form, while signed by both the resident and the physician, was missing a required indication that the resident was capable of making the decision. According to the facility's policy, a DNR form that is not fully completed is not considered valid for withholding CPR. The resident involved was admitted with a diagnosis of spinal stenosis and had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating no cognitive impairment. The care plan documented the presence of an advance directive for DNR and stated that the resident's wishes would be honored. During an interview, the DON confirmed that the form was incomplete and that, as a result, the resident would be treated as a full code.