Failure to Honor Advance Directive Leads to Unwanted CPR
Summary
The facility failed to honor a resident's advance directive, specifically a Do Not Resuscitate Order (DNRO), resulting in the resident receiving unwanted cardiopulmonary resuscitation (CPR). The incident involved a male resident with severe cognitive impairment and multiple health issues, including dementia and chronic kidney disease. Despite the resident's wife signing a DNRO form, the facility did not update the electronic medical record (EMR) to reflect the change in code status from Full Code to DNR. On the night of the incident, the resident was found unresponsive in his wheelchair. A Licensed Practical Nurse (LPN) initiated CPR without verifying the resident's code status in the EMR or the Code Status Binder. Emergency Medical Services (EMS) continued CPR upon arrival and transported the resident to the hospital, where he was intubated and later passed away after life support was withdrawn at the wife's request. The failure to update the EMR and verify the code status led to the administration of life-saving measures against the resident's explicit wishes. Interviews with facility staff revealed that the Assistant Director of Nursing (ADON) was responsible for updating the EMR but failed to do so due to being busy with other tasks. The Director of Nursing (DON) and other staff members were aware of the DNRO but did not ensure the EMR was updated. The incident highlighted a breakdown in communication and procedure adherence, resulting in the resident's advance directive not being honored.
Removal Plan
- A medical record audit was completed for current residents to ensure DNR forms were present in the electronic medical record for residents with DNR orders.
- Current licensed nurses were educated on resident's rights regarding treatment and Advanced Directives by the Director of Nursing/delegate.
- 40 out of 41 total licensed nurses received education; 98% of nurses: 10 out of 41 nurses completed the education, 24% of nurses, an additional 29 of 41 nurses completed their education, 71% of nurses. An additional 1 of 41 nurses completed the education, 2%. 1 remaining licensed nurse to receive education upon return from leave and prior to working next shift.
- New hire nurses at the facility will receive the above education during orientation and prior to working an assignment.
- Current licensed nurses participated in mock code drills: 18 out of 41 total Licensed Nurses participated in mock code drills; 44% of nurses: 11 out of 41 nurses participated in mock code drills, 27% of nurses. 7 out of 41 nurses participated in mock code drills, 17%. 23 remaining licensed nurses to participate in mock code drills upon return from leave and prior to working next shift.
- New hire nurses at the facility will participate in a mock code drill during orientation and prior to working an assignment.
- Residents and/or responsible parties for current residents residing in facility were interviewed by Social Services/Delegate to validate current physician orders for code status reflect resident and/or responsible party's current wishes for code status. Code status updated, if applicable based on interviews conducted.
- Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting completed with Medical Director, Administrator, and additional Interdisciplinary team (IDT) members on the adherence to CPR policy and policy and procedure for Resident Rights Regarding Treatment and Advance Directives and a review of the root cause analysis was completed.
- As part of the ongoing Quality Assurance Assessment (QAA) process, an ad hoc QAPI was conducted that included the Medical Director, Administrator, Director of Nursing and additional IDT members to review the plan viability on the Advance Directives process, code process and results of audits. No discrepancies or concerns were noted related to Advanced Directive code status standards and guidelines.
Penalty
Resources
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The facility did not timely implement and enter advance directive code status orders for two residents. One resident was discharged from the hospital with a DNRCCA status, but the facility delayed initiating any code status order and then entered the resident as Full Code despite signed DNRCCA paperwork later uploaded to the EHR. Another resident with multiple chronic conditions had DNRCCA paperwork signed and uploaded, but no corresponding code status order was entered into the EHR after readmission. Staff interviews confirmed these delays and omissions occurred despite facility policy requiring nurses to obtain and enter physician orders reflecting residents' executed advance directives.
A cognitively impaired resident with multiple serious diagnoses was documented in the facility record and care plan as full code, with an advance directive for CPR, even after admission to hospice. Hospice staff obtained and documented a DNR-CC advance directive signed by the resident’s spouse and reported that such documents are typically faxed to the facility, but no updated DNR orders appeared in the facility chart. On the day of death, hospice staff recognized the resident was actively dying, made him comfortable, and did not initiate CPR; facility staff also did not call a code, despite the MAR still listing full code status and an RN questioning this discrepancy and being told by a unit manager not to worry about it. The Administrator and DON acknowledged that the facility’s documentation did not match the hospice DNR-CC directive, contrary to facility policy requiring current advance directives to be maintained and communicated in the medical record.
A resident with severe cognitive impairment and multiple diagnoses was admitted with a DNRCC order, but during a medical emergency, an LPN found no Advance Directive information in the electronic record and a Full Code indicator in the physical chart, leading to the initiation of CPR. The DNRCC order had been signed and placed in the chart after a care conference, but no physician's order was entered and the code status was not updated in the system, resulting in the resident's wishes not being honored.
A resident with a physician's order for DNR-Comfort Care Arrest did not have signed DNR paperwork in the medical record. When the resident became unresponsive and pulseless, staff initiated CPR because the required documentation was missing, despite the DNR order. The DON confirmed the facility had not ensured the presence of signed DNR paperwork, leading to resuscitation efforts contrary to the resident's code status.
A resident with late onset Alzheimer's disease and a documented DNRCC-A order was found cyanotic and near arrest. Staff, including an LPN and RN, initiated CPR due to confusion about the DNRCC-A code status, providing chest compressions and respirations before stopping when the absence of a pulse and respirations was confirmed. The DON later acknowledged that staff misunderstood the advance directive and that CPR should not have been performed.
A resident with multiple medical conditions was admitted with conflicting documentation regarding code status, including both full code and DNRCC orders. Neither the electronic health record nor the paper chart contained a signed advance directive, despite facility policy requiring such documentation. Staff interviews confirmed the absence of the required advance directive in the medical record.
Failure to Timely Implement and Enter Advance Directive Code Status Orders
Penalty
Summary
The facility failed to ensure that residents' advance directives and code status orders were obtained and implemented timely upon admission or readmission. For one resident with diagnoses including hypertensive emergency, acute pulmonary edema, and Sjogren syndrome, the hospital discharge summary identified the resident as DNR-Comfort Care Arrest (DNRCCA) at the time of admission. However, no physician order for code status was initiated until several days later, and when it was entered, the resident was listed as Full Code. Although DNRCCA paperwork was signed by the physician and later uploaded into the electronic health record, the corresponding physician order in the record continued to reflect Full Code status. For another resident with conditions including a stage 4 pressure ulcer, paraplegia, generalized anxiety disorder, major depressive disorder, and neuromuscular bladder dysfunction, DNRCCA paperwork was signed by the physician and uploaded into the electronic medical record, but no physician order for code status was entered into the record following the resident’s readmission from a hospital stay. Interviews with the Regional Director of Clinical Services, the Vice President of Clinical Services, and the DON confirmed that code status orders were either delayed, incorrect, or missing, despite the facility’s policy requiring that, after execution of the Ohio Advance Directive form, a nurse obtain a physician order consistent with the resident’s wishes and enter that order into the electronic health record.
Failure to Maintain Current Hospice DNR in Medical Record and Code Status Discrepancy at Time of Death
Penalty
Summary
The deficiency involves the facility’s failure to maintain the most current and accurate advance directive in a resident’s medical record and to ensure that the documented code status matched the resident’s actual wishes as established through hospice. The resident had multiple diagnoses including muscle wasting and atrophy, depression, dementia with behavioral disturbance, dysphagia, hypertension, and diffuse large B-cell lymphoma, and was cognitively impaired per the admission MDS. The physician’s orders and care plan in the facility record documented the resident as "full code" with an advance directive for CPR, and the plan of care specified that the advance directive and code status would be honored and kept in the medical record at all times. No updated advance directive orders were found in the facility record after the resident’s admission to hospice. Hospice documentation showed that upon hospice admission, hospice staff discussed advance directives with the resident’s wife, who stated they did not want CPR or other life-sustaining measures if the resident’s heart or lungs stopped, and a DNR order (DNR-CC) was completed and signed by the wife. Hospice staff reported that these documents are typically faxed to the facility, and hospice records reviewed by the hospice RN showed a DNR-CC advance directive in place. However, the facility’s medical record continued to list the resident as full code, and the CNP confirmed that only full code status was evident in the facility’s documentation. The Administrator and DON were informed of the discrepancy between the facility’s documentation and the hospice DNR-CC documents and did not dispute the findings. On the day of the resident’s death, multiple staff interactions occurred while the facility record still reflected full code status. Hospice staff reported the resident was actively dying, transferred him from his wheelchair to bed, and made him comfortable. A CNA later found the resident unresponsive and reported this to a nurse; no code was called. An agency RN, who administered Morphine per hospice direction, noticed the full code status on the MAR and reported it to the unit manager/LPN, who told her not to worry about the code status and that it would be taken care of. Hospice staff documented that the resident expired and that CPR was not initiated, consistent with the hospice DNR-CC directive, but this directive was not present or reflected in the facility’s medical record as required by the facility’s advance directive policy, which calls for obtaining, filing, and communicating current advance directives and updating physician orders and the care plan accordingly.
Failure to Honor and Document Resident's Advance Directive Code Status
Penalty
Summary
The facility failed to ensure that a resident's Advance Directive and code status were accurately documented and honored. The resident, who was severely cognitively impaired and had diagnoses including diabetes, dementia, muscle weakness, depression, and breast cancer, was admitted with a Do Not Resuscitate; Comfort Care (DNRCC) order according to her wishes and those of her son, who was her Power of Attorney. However, during a medical emergency when the resident was found unresponsive, the LPN checked the electronic record and found no information regarding Advance Directives. Upon reviewing the physical chart, the LPN found a yellow sheet indicating Full Code status and initiated CPR, also calling emergency services. The resident's son was notified and arrived after the resident had expired. It was only discovered days later that the resident was actually a DNRCC at the time of the incident. Further review revealed that after a care conference with the resident's son, the Social Service Designee faxed the DNRCC form to the nurse practitioner, who signed and placed it in the physical chart. The Social Service Designee also notified an RN to update the order, but there was no physician's order for the DNRCC in the resident's chart, nor was the code status updated in the electronic record. The facility's policy required that residents' Advance Directive wishes be honored and documented, with appropriate physician orders written for those choosing Advance Directives. This failure to accurately document and communicate the resident's code status led to the initiation of CPR against the resident's documented wishes.
Failure to Maintain Signed DNR Documentation Resulted in Unwanted CPR
Penalty
Summary
The facility failed to ensure that signed Do Not Resuscitate (DNR) paperwork was present in the medical record for a resident who had a physician's order for DNR-Comfort Care Arrest (DNRCCA) code status. Record review showed that although the resident had a documented DNR order, there was no corresponding signed DNR paperwork in the chart. When the resident became unresponsive and was found without a pulse, staff initiated cardiopulmonary resuscitation (CPR), including chest compressions and bagging, until EMS arrived. The nursing progress note confirmed that CPR was performed because the required DNR documentation was not available in the medical record. Staff interviews confirmed that CPR was initiated due to the absence of signed DNR paperwork, despite the presence of a physician's order for DNR status. The Director of Nursing acknowledged that the facility had not ensured the necessary DNR documentation was present to prevent resuscitation efforts. This deficiency was identified during a complaint investigation and affected one resident out of those reviewed for advance directives.
Failure to Honor Resident's DNRCC-A Advance Directive
Penalty
Summary
Staff failed to honor a resident's documented code status regarding advance directives. The resident had a signed Do Not Resuscitate Comfort Care - Arrest (DNR CC-A) order, which specified that all interventions should cease at the point of cardiac or respiratory arrest, and no CPR should be performed. Despite this, when the resident was found cyanotic with a respiratory rate of three breaths per minute, staff initiated CPR, including chest compressions and respirations, before confirming the absence of a pulse and respirations. Interviews revealed that both the LPN and RN involved did not understand the meaning of the DNRCC-A order and proceeded with resuscitation efforts. The DON confirmed that staff were confused about the code status and that CPR should not have been initiated for a resident with a DNRCC-A order. The error was only recognized after emergency medical technicians arrived and confirmed the resident's DNR status.
Failure to Document Resident Advance Directive and Code Status
Penalty
Summary
The facility failed to obtain and maintain written documentation of a resident's code status and advance directive in the medical record. Upon admission, the resident was noted to have multiple diagnoses, including type two diabetes mellitus, severe sepsis, cellulitis, rheumatoid arthritis, and atrial fibrillation. The admission summary indicated the resident was alert and listed as a full code, while a physician order documented a Do Not Resuscitate Comfort Care (DNRCC) status. However, a subsequent physician progress note again listed the resident as a full code. Review of both the electronic health record (EHR) and the hard copy medical record revealed no copy of an advance directive, although the hard chart was labeled with DNRCC on the outside and the EHR banner also indicated DNRCC. Interviews with facility staff confirmed that there was no signed advance directive in either the paper chart or the EHR for the DNRCC code status. The Quality of Life Coordinator stated that code status was discussed during care conferences, but could not provide documentation of a signed directive. The Administrator confirmed that the resident was admitted with a DNRCC code status according to received records, but later discussions with the resident and family revealed a preference for full code status. The facility's policy required obtaining and placing copies of all advance directives in the medical record, but this was not done for the resident in question.
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