Failure to Enter and Care Plan DNR Order in Clinical Record
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including Non-Hodgkin lymphoma, muscle weakness, and an indwelling urinary catheter, had a documented advance directive indicating Do Not Resuscitate (DNR) status. Despite this, the resident's DNR order was not entered into the electronic clinical record upon admission or readmission, nor was it incorporated into the resident's care plan as required by facility policy. The advance directive was only found in the hard chart at the nursing station and not reflected in the electronic system, making it inaccessible to staff relying on electronic records for code status information. Interviews with nursing staff revealed that the process for entering advance directives into the electronic record was not consistently followed, and there was no centralized system, such as a code book, to alert staff to residents' code statuses. The responsible nurse was unable to locate the code status in the electronic record until after the deficiency was identified, at which point the order was entered. Facility policy requires a physician's order for DNR status and mandates that it be flagged in the chart and included in the care plan, but these steps were not completed for this resident.