Failure to Obtain Physician Signature on OOH-DNR Order
Penalty
Summary
The facility failed to ensure that a resident's Out-of-Hospital Do Not Resuscitate (OOH-DNR) order was valid, as the required physician's signature was missing from the form. The resident in question was an elderly male with multiple significant medical conditions, including acute kidney failure, dependence on renal dialysis, hypertension, hyperlipidemia, and heart failure. He was severely cognitively impaired and required regular dialysis treatments. Documentation showed that the resident's representative had requested DNR status, and the facility's records, including the electronic profile and care plan, reflected a DNR order. However, the OOH-DNR form lacked the physician's signature, rendering it invalid according to state requirements. Interviews with facility staff revealed a lack of clarity and consistency in the process for obtaining and finalizing OOH-DNR orders. Nursing staff, the ADON, and the SW all confirmed that the resident was listed as DNR in the electronic record, but upon review, the OOH-DNR form was found to be incomplete due to the missing physician signature. The SW, who was responsible for auditing OOH-DNR forms, acknowledged the deficiency and stated that the facility was still waiting for the physician to sign the document. The DON and other staff described a process in which the OOH-DNR form was initiated at admission, signed by the resident or representative, and then routed through various departments before being presented to the physician for signature. Delays in obtaining the physician's signature were attributed to the physician's availability and the process of delivering the form to the physician's office. Despite the lack of a valid OOH-DNR form, staff indicated that they would honor the family's wishes based on the signed request for DNR status, even though the form was not legally valid without the physician's signature. The Medical Director stated that the OOH-DNR should be signed within 24 hours of the order being entered into the electronic record, and that without the physician's signature, the resident would be considered full code. Facility policy and state guidance both require a properly executed OOH-DNR form, including all necessary signatures, for the order to be valid and honored by health professionals.