Failure to Maintain Valid Advance Directive Documentation for DNR Orders
Penalty
Summary
The facility failed to ensure that three residents had valid advance directive documents on file, specifically regarding Do Not Resuscitate (DNR) orders. For one resident with hypertensive heart disease and heart failure, the care plan and facility records indicated DNR status, but the Durable Do Not Resuscitate Order from the Virginia Department of Health lacked a physician's signature, rendering it invalid. Despite the resident being cognitively intact and on hospice, the absence of a valid physician signature meant the DNR order could not be honored. Another resident with dementia and severe cognitive impairment was listed as DNR in the order summary, but the only advance directive document on file was for the resident's deceased spouse, not the resident herself. The responsible party confirmed the resident's DNR status, but no valid documentation existed in the medical record. Facility staff acknowledged the error and confirmed that the necessary documents were missing or incorrect. A third resident with multiple diagnoses, including severe cognitive impairment, had a DNR form in the clinical record that was unsigned by the authorized person, making it invalid. Staff interviews confirmed that without a signature, the DNR order was not legal, and the resident would receive CPR in an emergency. Facility policy required that valid advance directives be obtained, documented, and placed in the resident's record, but this process was not followed for these residents, resulting in incomplete or invalid documentation for their code status.