Failure to Ensure Valid Completion of OOH-DNR Form
Penalty
Summary
A deficiency occurred when a resident's Out-of-Hospital Do Not Resuscitate (OOH-DNR) form was found to be incomplete and therefore invalid. The resident, who had diagnoses including paraplegia, cirrhosis of the liver, and sepsis, was documented as having intact cognition and had requested a DNR status. The resident's care plan and face sheet both indicated a DNR order, and the OOH-DNR form was present in the record. However, upon review, it was discovered that the required signatures in the final section of the OOH-DNR form were missing for the resident and the witnesses, with only the physician's signature present. The form's instructions specified that all parties who signed above must also sign below to acknowledge proper completion. During interviews, the Social Worker confirmed that the missing signatures rendered the OOH-DNR form invalid and acknowledged responsibility for ensuring the correct execution of such forms. The Administrator also confirmed the expectation that all OOH-DNR forms be fully and accurately completed. Facility policy required verification of advance directive documentation for accuracy, and state guidance indicated that improperly completed forms may not be honored by health professionals.