F0578

D

Failure to Obtain Physician Signature on OOH-DNR Order

Brownsville, Texas Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

The facility failed to ensure a resident’s right to formulate and implement an advance directive by not obtaining the physician’s signature on an Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) order. The resident was an older female with diagnoses including nontraumatic intracerebral hemorrhage in the cortical hemisphere, other toxic encephalopathy, pneumonia due to inhalation of food and vomit, and Wernicke’s encephalopathy. Her Quarterly MDS showed a BIMS score of 09, indicating moderate cognitive impairment, with unclear speech and intermittent ability to understand and be understood. The comprehensive care plan identified the resident as DNR, initiated and revised on the same date, and a progress note documented that the resident’s representative requested a change from full code to DNR. The order summary also reflected a DNR order.

The OOH-DNR form for this resident, dated the same day as the DNR order, contained the signatures of the resident’s representative and two witnesses but lacked the attending physician’s signature, as required by the OOH-DNR instructions and the facility’s policy on residents’ rights regarding treatment and advance directives. During interviews, the social services staff member, the DON, and the Administrator each acknowledged that the physician had not signed the OOH-DNR at the time, yet stated that the DNR would be honored in-house if an event occurred. The OOH-DNR instructions specified that the attending physician must sign the form and document the existence of the order in the permanent medical record, and that the order must be signed and dated by two witnesses and, when applicable, by the physician in the designated section. The absence of the physician’s signature on the OOH-DNR constituted the deficiency.