Failure to Accurately Document and Update DNR Status in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who was admitted with a terminal prognosis and expressed a clear desire to have Do Not Resuscitate (DNR) status. Although the resident, who was alert and oriented, signed an Out-of-Hospital (OOH) DNR upon admission and the document was subsequently signed by the physician, the DNR order was not updated in the resident's physician orders or uploaded into the electronic medical record. The care plan also did not reflect the resident's code status, and the active physician orders continued to indicate the resident was a full code without an end date. Interviews with facility staff revealed that the admission director facilitated the DNR signing and passed the document to the social worker (SW) for physician signature and family notification. However, the SW was absent during this period, and although the DNR was faxed to and signed by the physician, it was not properly integrated into the resident's medical record. The administrator acknowledged the failure to upload the DNR and update the care plan, noting that the DON or designee was responsible for ensuring medical records were complete. This lapse resulted in incomplete documentation of the resident's code status at the time of death.