Failure to Ensure Proper Completion of Advance Directive (DNR) Form
Penalty
Summary
The facility failed to ensure that all residents had the right to formulate an advance directive, as evidenced by a missing date on a Do Not Resuscitate (DNR) form for one resident. Record review showed that the resident, who was cognitively intact and had a diagnosis of malignant neoplasm of the bronchus or lung, had a DNR order in his file that was signed by both the resident and the physician, but the date of the resident's signature was missing. The facility's policy required that advance directives be properly completed and recognized under state law, but this DNR form was not fully completed as required. Interviews with staff, including an LVN and the DON, confirmed that the missing date rendered the DNR invalid, and staff acknowledged that this oversight could result in the resident's wishes not being honored in an emergency. The DON stated that all staff, including herself, were responsible for checking DNR forms for accuracy during care plan meetings, but this particular form was missed. The facility's failure to ensure the DNR was properly completed could have led to the resident not receiving care in accordance with his wishes.