Incomplete OOH-DNR Documentation for Resident
Penalty
Summary
The facility failed to ensure that a resident's Out-of-Hospital Do Not Resuscitate (OOH-DNR) form was completed in accordance with requirements. Specifically, the OOH-DNR for a male resident with Parkinson's disease, who was cognitively intact and aware of his DNR status, was missing the Medical Power of Attorney's (MPOA) printed name, the date the document was signed by the MPOA, and the notary's signature. The resident's care plan indicated he was a DNR and that his advanced directive options and rights were to be reviewed with him and his family. Interviews with facility staff revealed confusion regarding responsibility for ensuring DNR forms were properly completed. The Regional Social Worker acknowledged the missing information on the resident's OOH-DNR and stated that the Administrator and Director of Nursing (DON) were responsible for overseeing DNR accuracy. The Administrator confirmed the expectation that DNRs be fully completed, including all required signatures and dates, and identified the Regional Social Worker as responsible for monitoring DNRs. Facility policy required inquiry about advance directives upon admission and respect for such directives in accordance with state law.