Failure to Document DNR Order per Advanced Directives Policy
Penalty
Summary
The facility failed to follow its advanced directives policy by not obtaining a physician's order for Do Not Resuscitate (DNR) for one resident who had indicated a preference for DNR status. The resident's Do-Not Resuscitate/Practitioner Orders for Life-Sustaining Treatment (POLST) form, dated several years prior, clearly documented the resident's wish to not have cardiopulmonary resuscitation attempted. However, a review of the resident's current Physician's Order Sheet did not show any documentation of a DNR order. During an interview, a registered nurse explained that the standard procedure involves social services discussing code status with the resident upon admission, completing the necessary forms, and obtaining signatures from both the resident and physician before entering the order into the electronic medical record. Upon reviewing the resident's electronic record, the nurse confirmed that there was no DNR order present and nothing indicating the resident's code status in the system. The facility's policy requires that advance directive information be added to the Physician Order Sheet, but this was not done for the resident in question.