Incomplete Advance Directive Documentation for DNRCC-A Status
Penalty
Summary
The facility failed to ensure that a resident's advance directive orders and information were accurate and complete throughout the medical record. Specifically, a resident with diagnoses including Alzheimer's Disease, bipolar disorder, and post-traumatic stress disorder was admitted with a physician's order for Do Not Resuscitate Comfort Care Arrest (DNRCC-A) status. However, review of the hard medical chart revealed that the DNRCC-A order was unsigned by a physician and only contained the resident's name. The plan of care and physician's orders both indicated DNRCC-A status, but the required documentation was incomplete. The Director of Nursing confirmed that the DNRCC-A form lacked a physician's signature, contrary to facility policy supporting residents' rights regarding treatment and advance directives.