Mid Valley Nursing & Rehabilitation failed to obtain physician signatures on out-of-hospital DNR forms, even though the facility's Advanced Directives policy explicitly states medical providers must sign the documents according to form instructions.
The Director of Nursing told inspectors during a December 31 interview that she had received a verbal order from a doctor to change a resident's code status to DNR. She said there was "not a negative outcome because she had the verbal order."
But the facility's own policy contradicts that approach.
The nursing home's Advanced Directives policy, reviewed and revised on an unspecified date, states that staff "should obtain the medical provider/physician's signature as per the OOH DNR form instructions" when implementing advance directives.
Social Services staff reinforced this requirement during interviews with inspectors. They explained that doctor signatures are necessary "because it makes the document official, a legal document that all parties signs." The Social Services department stated clearly that "the DNR was not complete until the doctor signed it."
The Director of Nursing acknowledged that the social worker was responsible for completing out-of-hospital DNR forms. She described the facility's process: staff explain the document to residents, and "if they say yes that they want to be DNR, the facility would obtain the resident/RP and witnesses signatures."
Missing from that process was the physician signature required by both facility policy and the DNR form itself.
Do Not Resuscitate orders carry profound consequences for residents and their families. These documents direct emergency medical personnel and healthcare providers not to perform cardiopulmonary resuscitation if a person's heart stops or they stop breathing.
The distinction between verbal orders and signed documentation can prove critical in emergency situations. While verbal orders may suffice for some medical decisions within a facility, DNR forms are designed to travel with patients and communicate their wishes to paramedics, hospital staff, and other providers who have no access to internal facility records.
The inspection found that Mid Valley's practices fell short of its own written standards. The facility policy requires the interdisciplinary team to "honor the care decision expressed and initiate the advance directive by initiating the out of hospital Do Not Resuscitate (OOH DNR) form" with proper physician signatures.
Federal inspectors classified the violation as causing "minimal harm or potential for actual harm" affecting "few" residents. However, the deficiency strikes at fundamental questions of resident autonomy and proper documentation of life-and-death decisions.
The gap between the Director of Nursing's verbal order approach and the facility's written policy suggests confusion about proper procedures among staff responsible for implementing residents' end-of-life wishes.
Advanced directives and DNR orders represent some of the most sensitive decisions residents and families make during nursing home stays. Proper documentation ensures these wishes are respected across different care settings and by various medical personnel who may encounter the resident.
The facility's policy acknowledges this reality by requiring physician signatures on DNR forms. But the Director of Nursing's reliance on verbal orders alone suggests the policy wasn't being followed consistently.
Mid Valley Nursing & Rehabilitation operates at 601 N Mile 2 West in Mercedes, a border city in South Texas. The facility serves residents who may transfer between the nursing home, hospitals, and other care settings where properly executed DNR documentation becomes essential.
The inspection was conducted in response to a complaint, though the report doesn't specify the nature of the original concern that prompted the investigation.
Federal inspectors completed their review on December 31, 2025, documenting the deficiency under regulation F 0578, which addresses resident rights and facility compliance with advance directive requirements.
The violation highlights ongoing challenges nursing homes face in balancing efficient care delivery with proper documentation requirements. While verbal orders may seem sufficient for internal purposes, legal documents like DNR forms require complete execution to protect both residents and facilities.
For residents and families at Mid Valley, the incomplete DNR documentation could have created uncertainty about whether their end-of-life wishes would be properly communicated and honored across different care settings.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mid Valley Nursing & Rehabilitation from 2025-12-31 including all violations, facility responses, and corrective action plans.
Additional Resources
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