Failure to Ensure DNR Order Entered in Medical Record
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a physician's order for Do Not Resuscitate (DNR) status was present in the medical record for one resident upon readmission. The resident, a male with acute and chronic respiratory failure and moderately impaired cognition, had a care plan and an Out-of-Hospital DNR form indicating DNR status. However, the physician's order for DNR was not entered into the electronic medical record at the time of readmission. Interviews with the ADON, DON, and Administrator confirmed that the process for entering and monitoring such orders was not followed, resulting in the omission. The facility's policy required that all documents regarding decision-makers and DNR orders be included in the resident's medical record. The ADON acknowledged that the order was missed during the admission process, and both the DON and Administrator stated that it was the responsibility of the charge nurse to input the code status and for the ADON to monitor the orders. The absence of the DNR order in the resident's chart was identified through record review and staff interviews.