Failure to Maintain Signed Advanced Directive for DNR Status
Penalty
Summary
The facility failed to ensure that a signed copy of an advanced directive, specifically indicating whether to perform cardiopulmonary resuscitation (CPR) or to implement a do not resuscitate (DNR) order, was present in the medical record for one resident. Documentation including the resident's face sheet, care plan, and admission checklist identified the resident as DNR, and the resident verbally confirmed their wish for DNR status during an interview. However, the medical record did not contain a signed advanced directive by the resident or their representative and the provider. The DON confirmed that the process required a signed provider order and advanced directive upon admission, and that the resident was not listed as wanting CPR, but was unable to locate the required signed document. Additionally, a policy related to advanced directives was requested but not provided.