Failure to Maintain Signed DNR Documentation in Clinical Record
Penalty
Summary
The facility failed to ensure that a resident’s documented Do Not Resuscitate (DNR) status was supported by a signed DNR document in the clinical record. The resident had a diagnosis of atrial fibrillation and an admission MDS showing a BIMS score of 12, indicating moderately impaired cognition. Her care plan documented that she chose to be a DNR and stated that the DNR order would be part of the medical record and reviewed with the care plan. The EMR also contained a physician’s order for a DNR. However, the EMR lacked evidence of the actual signed DNR document that was required to accompany the physician’s order. During the survey, the resident was observed in the dining room visiting with another resident. Administrative Nurse D reported that during the resident’s transfer from assisted living to long-term care, the signed DNR did not transfer into the current chart. Administrative Nurse D also stated that the facility did not have a process or system in place to monitor or verify changes for advance directives. The facility’s undated Advance Directives policy stated that a physician’s DNR order would be accompanied by supporting documentation in the resident’s clinical record, but this supporting documentation was not present for this resident.
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