Invalid OOH-DNR Form Due to Missing Physician Signature
Penalty
Summary
A deficiency occurred when a resident's Out of Hospital Do Not Resuscitate (OOH-DNR) form was found to be invalid due to a missing physician signature. The resident, who had diagnoses including end stage renal disease and dependence on renal dialysis, was cognitively intact and had elected DNR status as documented in the care plan. The resident had signed the OOH-DNR form, and the physician had signed the upper portion, but failed to sign the required lower portion of the form. During interviews, the Social Worker confirmed that two signatures were required from all parties on the OOH-DNR form and acknowledged that the missing physician signature rendered the form invalid. The Social Worker stated it was her responsibility to ensure the forms were correctly executed and identified the error as an oversight. The DON also confirmed the expectation that all advance directives, including OOH-DNR forms, be properly completed to honor residents' end of life wishes. Facility policy and state guidance both require correct completion of these forms.