Failure to Maintain Consistent DNR Documentation in Designated Locations
Penalty
Summary
The deficiency involves the facility’s failure to maintain a resident’s advance directive documentation in both locations designated by facility policy. A cognitively intact resident, admitted with an existing Do Not Resuscitate (DNR) status, reported that he had informed the facility of his DNR upon admission and understood it to mean that staff would not perform CPR if needed. The resident’s physician orders contained an advanced directive order for DNR, and the electronic medical record (EMR) displayed a DNR status in the advance directive banner at the top of the resident’s EMR page. However, when surveyors reviewed the advance directive notebook kept at the nurse’s station, there was no DNR form on file for this resident, despite the EMR and physician orders indicating DNR status. A nurse stated that she would look either in the advance directives notebook or in the EMR to determine a resident’s code status. The Interim DON confirmed she was responsible for ensuring the notebook matched the EMR and for obtaining provider signatures on DNR forms, and acknowledged that the resident’s DNR form was missing from the notebook. The Administrator also stated that code status information in the advance directives binder and EMR should match and that staff were expected to check either source for code status.
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