Failure to Complete and File Physician-Signed DNR Form
Penalty
Summary
The facility failed to ensure that a Do Not Resuscitate (DNR) form was completed and signed by a physician and included in the medical record after a physician ordered DNR status for a resident. The resident, who was admitted with a diagnosis of malignant neoplasm of the gallbladder and was on hospice care, had a physician's order for DNR documented in the medical record. However, upon review, there was no evidence that the required DNR form had been completed or signed by the physician. The resident was severely cognitively impaired and had a condition with a life expectancy of less than six months. The care plan documented the resident as DNR, with goals and interventions reflecting this status. Despite this, the necessary DNR documentation was missing from the medical record. Staff interviews revealed that the process for completing and signing DNR forms was not followed in this case, and an audit of advanced directives had overlooked this resident.