Failure to Ensure Proper Completion of Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that a resident's right to formulate an advance directive was properly honored. A review of the resident's records revealed that a Do Not Resuscitate (DNR) order was present but was not properly completed, as the physician's signature was not dated. The paper DNR was signed and dated by the resident and two witnesses, but the physician's signature lacked a date, rendering the document incomplete. Interviews with facility staff, including the LVN, ADON, SW, and DON, confirmed that the DNR was not valid due to this omission, and there was confusion among staff regarding responsibility for ensuring the DNR was correctly completed and maintained. Further review found that a second DNR document obtained from the hospice agency was also invalid, as both witnesses were direct care staff, which did not meet the requirements outlined in the DNR instructions. The facility's policy stated that advance directives would be respected in accordance with state law and facility policy, but the documentation and staff interviews demonstrated that this was not followed in practice. The resident, who had significant medical conditions and was on hospice care, expressed her wish to be a DNR, but due to incomplete and improperly executed documentation, her wishes were not properly documented or ensured.