Failure to Obtain Physician Signature on OOH-DNR Form
Penalty
Summary
The facility failed to ensure that a resident's Out-of-Hospital Do Not Resuscitate (OOH-DNR) form was properly completed, specifically lacking the required physician's signature. The resident, an elderly female with diagnoses including Type 1 Diabetes Mellitus, muscle wasting and atrophy, and dehydration, was admitted with a documented DNR status on her electronic face sheet, care plan, and physician orders. However, review of the OOH-DNR form revealed it was undated and missing the attending physician's signature in the designated sections, which is necessary to make the document official and legally binding. Interviews with facility staff, including the ADON, Social Services, and DON, confirmed that while the DNR status was discussed and documented in the electronic record, the OOH-DNR form was not fully executed as required. The Social Services staff member, responsible for completing the form, acknowledged that the physician's signature is essential for the document's validity. The DON stated that a verbal order from the physician was obtained and used to update the code status, but the OOH-DNR form itself remained incomplete without the physician's signature. Facility policy requires the physician's signature on the OOH-DNR form to implement advance directives, which was not followed in this instance.