Failure to Obtain and File Required DNR Documentation Before Changing Code Status
Penalty
Summary
The facility failed to ensure that a resident's right to formulate an advance directive was honored. Specifically, a female resident with cognitive impairment and multiple medical diagnoses was admitted with a care plan indicating Full Code status, meaning CPR would be performed if needed. However, a physician's order for Do Not Resuscitate (DNR) was later entered without a completed and signed Out of Hospital-Do Not Resuscitate (OOH-DNR) form in the resident's medical record. The responsible party for the resident confirmed that the OOH-DNR paperwork had not been signed or returned, despite the resident's wishes to be DNR. Interviews with facility staff revealed that the code status was documented on the face sheet and admission orders, and that a copy of the OOH-DNR must accompany the resident if transferred to a hospital. Staff stated that the signed OOH-DNR form should be on file before changing code status orders, and the facility's policy required the original DNR order and completed OOH-DNR to be filed in the medical record. The lack of a completed OOH-DNR prior to the physician's DNR order resulted in the resident's advance directive wishes not being properly documented or honored according to facility policy.