Failure to Honor Resident's Advance Directives
Penalty
Summary
The facility failed to honor the advance directive wishes of a resident, leading to inappropriate medical intervention. The resident, who had a do not resuscitate (DNR) and do not intubate (DNI) order documented in their Medical Orders for Life Sustaining Treatment (MOLST) form, experienced respiratory failure during a mechanical lift transfer. Despite the resident's advance directives, cardiopulmonary resuscitation (CPR) was initiated by a Licensed Practical Nurse (LPN) before the resident's code status was verified. The LPN performed approximately 30 chest compressions before a social worker confirmed the resident's DNR/DNI status, at which point CPR was ceased. However, upon the arrival of a Registered Nurse Supervisor, CPR was resumed due to a misunderstanding of the resident's code status. The supervisor instructed the continuation of chest compressions despite being informed of the resident's DNR status. This led to further confusion and the involvement of emergency medical services, who eventually ceased all life-saving measures upon re-confirmation of the resident's DNR/DNI status. The resident was pronounced deceased shortly thereafter. The incident highlighted a lapse in communication and adherence to the resident's advance directives, resulting in a care plan violation. The misunderstanding and miscommunication among staff members, particularly the actions of the Registered Nurse Supervisor, contributed to the failure to honor the resident's documented wishes, turning a potentially peaceful death into a chaotic situation.
Plan Of Correction
Plan of Correction: Approved January 10, 2025 FoltsBrook Center for Nursing and Rehabilitation is committed to ensuring that advance directive wishes are honored. 1. Resident #1 was discharged from the facility. The RN Supervisor was terminated. 2. All residents are at risk of this deficient practice. An audit was conducted on all residents’ Advance Directives. No further issues were identified. 3. The facility’s Advance Directives Policy and Procedure was reviewed. An audit will be conducted to ensure resident’s code status is accurate across the indicators (Order and MOLST). This audit will be conducted monthly for 3 months. The audit results will be reviewed during the facility’s monthly QA meeting. The frequency and duration of the audit will be re-evaluated at the end of the 3-month period. Also, Code Blue drills will be implemented monthly for 3 months. Those drills will be reviewed during the facility’s monthly QA meeting. The frequency and duration of the drills will be re-evaluated at the end of the 3-month period. 4. All nursing staff will be educated on the Advanced Directives Policy and Procedure including the difference between CPR and DNR; and indicators for resident’s code status (Order and MOLST). 5. Director of Nursing