Failure to Obtain Physician Order for DNR Status
Penalty
Summary
The facility failed to obtain a physician order to implement an advanced directive/Do Not Resuscitate (DNR) for one resident. The resident, who had moderate cognitive impairment and a full legal guardian authorized to make health and medical care decisions, had an advanced directive form signed by the guardian and witnessed, with a physician signature present on the form. However, upon review of the clinical record, it was found that there was no corresponding physician order in place to enact the DNR status. Interviews with facility staff revealed that the process for updating orders relies on notification from the social worker, but the Assistant Director of Nursing was not notified that the advanced directive had been signed, and the responsible social worker was unavailable for interview during the survey.