Failure to Obtain Physician Signature on OOH-DNR for a Resident with DNR Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) order was properly completed in accordance with the resident’s advance directive and the facility’s own policy. The resident was an elderly female with dementia, Type 2 diabetes mellitus, orthopedic aftercare following a nondisplaced fracture of the left femur, cerebral infarction affecting the right dominant side, and heart disease. Her Quarterly MDS showed a BIMS score of 03, indicating severe cognitive impairment. Her comprehensive care plan documented an advanced directive with a DNR code status, including interventions such as ensuring a signed DNR in the medical record, not calling 911 or initiating CPR in the event of cardiac arrest, keeping the resident comfortable, sending a copy of DNR paperwork upon transfer, and consulting social services if the family wished to change code status. The physician’s orders also reflected a DNR status. Record review of the resident’s OOH-DNR form showed that it had been executed by the resident’s adult child as a qualified relative in Section C, but the attending physician had not signed in Section E (Physician’s Statement) or Section F (acknowledgment that the document was properly completed). The OOH-DNR instructions specified that the attending physician must document the existence of the order in the medical record and sign the appropriate sections of the form, along with the required witnesses. Despite the care plan directive to ensure a signed DNR in the medical record, the physician’s signature was missing from the OOH-DNR form at the time of the survey. Interviews with staff clarified the internal process and where it broke down. The social worker stated she was responsible for reviewing advance directives with the family, obtaining the family’s signature, and then giving the OOH-DNR to another staff member, who was responsible for obtaining the physician’s signature. That staff member reported that the social worker would scan OOH-DNRs to her, and she would email the physician for signature, and that the physician typically signed within a day or two; she stated that in this case the physician’s signature was delayed by the physician’s office. The DON acknowledged that the resident’s DNR had been care planned and ordered, but the OOH-DNR form itself had not been signed by the physician as required, despite the facility’s policy to support and facilitate residents’ rights to formulate and implement advance directives and to place copies of existing directives in the chart and communicate them to staff.
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