Incomplete OOH-DNR Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that two residents' Out-of-Hospital Do Not Resuscitate (OOH-DNR) documents were properly completed, specifically lacking the required physician's signature and license number. Both residents had severe cognitive impairment, as indicated by a BIMS score of 03, and had diagnoses including Alzheimer's disease, non-Alzheimer's dementia, hypertension, and depression. Their care plans and physician orders reflected a DNR status, and the care plans included approaches to honor the DNR wishes and consult with responsible parties. Upon review, it was found that the OOH-DNR forms for both residents were signed by the residents or their medical power of attorney but were missing the physician's statement, signature, date, and license number, rendering the documents invalid. The forms were present in both the residents' electronic medical records and in a binder maintained by the social worker, but neither contained the necessary physician information. The social worker stated that while she assisted with the initiation of these documents and performed audits to ensure forms were on file, she did not always verify the completeness of documents that were initiated prior to her tenure or by outside agencies such as hospice. Interviews with the DON and Administrator confirmed that the social worker was responsible for monitoring advanced directives and that the incomplete OOH-DNR forms had not been previously identified. The facility's policy required residents to be informed of the opportunity to file advance directives upon admission and at least annually, with social services responsible for maintaining current and complete records. However, the lack of physician signatures on the OOH-DNR forms for these two residents constituted a failure to ensure that residents' end-of-life wishes were properly documented and could be honored.