Failure to Honor DNR Order and Resident Rights
Summary
The facility failed to honor a resident's documented Do Not Resuscitate (DNR) order as indicated in the Physician Orders for Life-Sustaining Treatment (POLST) and other medical records. When the resident was found not breathing, multiple nursing staff, including RNs and LVNs, initiated and continued cardiopulmonary resuscitation (CPR) for seven minutes without verifying the resident's code status. The decision to start CPR was based solely on an unidentified person shouting that the resident was a full code, rather than checking the resident's POLST, Admission Record, or electronic health record, all of which clearly indicated a DNR order. The involved staff, including those who performed CPR and those who assisted, admitted during interviews that they did not check the resident's code status and instead relied on the verbal assertion from an unidentified individual. The resident's POLST, Admission Record, and care plan all indicated DNR status, and the resident had previously expressed his wish for DNR due to his medical condition, including a cancer diagnosis. Despite these clear directives, the staff proceeded with resuscitation efforts until paramedics arrived and identified the DNR order in the resident's documentation. Facility policy and procedures required staff to verify code status and honor residents' rights to refuse life-sustaining treatment. However, these procedures were not followed during the emergency. The Director of Nursing and other staff acknowledged that the resident's wishes were not respected and that the failure to verify code status before initiating CPR was a violation of both facility policy and the resident's rights.
Removal Plan
- The Social Services Director (SSD), the DON, and the Assistant DON (ADON) conducted an in-house audit of each resident's POLST, Advance Directive, and History & Physical (H&P) exam to determine if the resident had the capacity to make decisions and to verify the resident's responsible party if the resident did not have the capacity to make decisions.
- The Interdisciplinary Team (IDT) reviewed the medical record of all residents and verified which residents were Full Code, which were DNR, and which had advanced directives.
- RNC 2 provided reinforcement training to LVN 1, RN 1, RN 2, and RNC 1 on Resident Rights, POLST, Communication of Code Status, CPR, DNR, Advance Directive, and Medical Emergency Response.
- The SSD and the DON met with residents who had the capacity to make their own decisions and verified that their POLST was current.
- The SSD and the DON spoke with the resident representative of each resident who did not have the capacity to make decisions, to verify if their POLST is current. All the resident representatives stated that the POLST is current and there are no changes.
- The Medical Records Director (MRD) printed current Admission Record (face sheets) of each resident reflecting the verified POLST.
- The ADON printed out the list of all residents with their Code Status Orders Report (based on the POLST) and visibly posted the list at each nurses' stations, emergency cart, and in a binder at the medication carts. The Code Status Order Report will be updated daily by the 11pm to 7am licensed nurses and checked for accuracy. The 7am to 3pm licensed nurses will update any report not completed during the prior 11pm to 7am shift.
- The DON placed DNR stickers on the outside of the confirmed DNR residents' medical records to clearly display their DNR status. The 11pm to 7am licensed nurses were tasked to reconcile the Code Status Order Report daily with the DNR stickers and update as necessary. The MRD will audit the DNR stickers on the medical records and reconcile it with the Code Status Order Report weekly to ensure accuracy. The audit will be documented utilizing a Code Status audit form. Any inaccurate findings will be immediately corrected by MRD. The Code Status audit form will be available in the facility's binder with all documents related to the IJ Situation (IJ Binder).
- The licensed nurse assigned to the desk work will discuss resident code status during huddle for all three shifts. During the huddle the nursing supervisor will assign a licensed nurse as the Shift Code Leader should any incident occur.
- The SSD placed red wristbands (to visually identify DNR status) on the wrists of residents with DNR orders with their consent. Residents with DNR status agreed to wear the red wristbands. The IDT updated the Care Plans of the residents with DNR orders. All licensed nurses are tasked to print the code status report and visually verify that red wristbands are worn by the residents with orders for DNR and document it on the DNR Form list. The MRD will audit residents' care plans weekly utilizing the Code Status audit form to ensure compliance and accuracy.
- The ADM updated the Person-Centered Interview and Rounding Worksheet to reflect the wristband section for department managers to visually verify that the wristband is intact on their assigned residents on Monday through Friday basis. Registered Nurse (RN) supervisor will conduct the audit on weekends utilizing Weekend Room Round form. Department Managers and RN supervisor will utilize the Code Status Order Report to ensure accuracy during rounds. The Person-Centered Interview and Rounding Worksheet and Weekend Room Round forms will be available the Room Rounds binder.
- A mandatory facility-wide in-service training was conducted to reinforce the facility's P&P including Resident Rights, POLST, Communication of Code Status, CPR, DNR, Advance Directive, and Medical Emergency Response. 100% of the staff received the in-service training. New hires will be educated prior to the start of their first scheduled shift.
- The ADM or the DON will interview employees from different shifts on weekly basis to validate understanding of the in-service training on Resident Rights, POLST, Communication of Code Status, CPR, DNR, Advance Directive, and Medical Emergency Response. Employee response will be recorded utilizing an Employee Validation form. The form will be available in the IJ Binder.
- Regular audits during IDT meetings will include verification of the residents' clinical record for the current code status. Newly admitted residents' code status will be reviewed during IDT meetings. The audit will be done upon admission and readmission of residents, weekly for current residents or when where there is a change in residents' code status. The audits will be documented utilizing the Code Status audit form and will be reported by the MRD during Monday through Friday operations meeting for appropriate follow up.
- The IDT conducted Root Cause Analysis (RCA) and identified the following: a. Code status was not immediately visible during an emergency requiring life-saving measures if appropriate. b. There was a lack of visual cues such as DNR sticker or resident identifier such as red wristbands.
- A QAPI (Quality Assurance & Performance Improvement) was implemented to track and report on above audit findings. The findings will be presented at the monthly QA Committee meeting for a minimum of three months for review and recommendations. After the initial three months, the QA Committee will decide regarding the continued frequency of audits and subsequent reporting, with audits continuing at least monthly to sustain compliance.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Two residents on physician-ordered modified diets (pureed and mechanical soft with nectar-thick liquids) were given Regular Menus listing items such as fresh fruit, salad greens, and grilled cheese that were not compatible with their diet orders. Both residents selected items from these Regular Menus, but the facility either could not provide the chosen foods due to diet restrictions or substituted different items (e.g., canned peach halves instead of fresh fruit), despite the residents’ expressed preferences. The RD and dietetic technician confirmed that Regular Menus were routinely provided to all residents, including those on mechanically altered diets, leading to menu choices that did not align with ordered diet consistencies.
A resident with severe cognitive impairment who used a wheelchair for mobility was observed being quickly pulled backward down a hallway while reclined in a geriatric chair, instead of being pushed forward in a dignified manner. The NA reported he pulled the chair backward because he felt it was harder to push forward, and he was unaware of any equipment problems. A SW later tested the same geriatric chair and found it functioned properly. Facility leadership, including the Staff Development Director, DON, and Administrator, stated that staff are educated on residents’ rights, dignity, and wheelchair use, and confirmed the expectation that residents be pushed forward in wheelchairs and geriatric chairs at a normal, dignified pace.
Multiple residents reported that staff frequently ignored call lights, delayed or refused assistance with toileting and transfers, and left individuals in soiled briefs or on bedpans for extended periods, causing discomfort and skin irritation. Residents described staff using cell phones and earbuds instead of attending to care needs, sitting in breakrooms while residents waited in the dining room late into the evening, and rushing care, including cleaning a resident with a pillowcase due to lack of washcloths. Several residents stated they felt dehumanized, invisible, and fearful of retaliation if they complained, and one noted that discussions with administration focused on profit rather than patient care. The administrator acknowledged that the facility failed to provide services in an atmosphere of dignity and respect for multiple residents.
A resident repeatedly experienced his pants slipping down and exposing part of his buttocks while standing and walking in common areas, including the dining room and nurse’s station, requiring him to hold up his pants and leading another resident to comment on what she saw. Staff interviews indicated they were aware the clothing did not fit properly, and facility policy states residents must be treated with respect and dignity and that care should emphasize comfort and personal needs, including appropriate clothing.
A resident with a history of CVA, dementia, and HTN was observed seated in a wheelchair in the main dining room while being fed by the DON, who remained standing throughout the feeding interaction. During surveyor observation and subsequent interview, the DON confirmed they were not seated while feeding the resident, contrary to required practice, resulting in a failure to provide a dignified dining experience.
Surveyors found that staff failed to maintain resident dignity during personal care and catheter management. In one case, a CNA removed a resident’s shirt without closing the privacy curtain while the roommate was present. In another case, a resident’s urinary catheter bag was left uncovered and visible from the hallway with the room door open, despite facility policy requiring catheter bags to be covered to promote dignity.
Failure to Honor Diet-Appropriate Menu Choices for Residents on Modified Diets
Penalty
Summary
The facility failed to provide residents with menu choices that matched their physician-ordered diet textures and liquid consistencies. One resident with severe cognitive impairment had a physician order for a controlled diet with pureed texture and honey-thick liquids. During a noon meal observation, this resident’s meal ticket was stapled to a Regular Menu listing items such as lettuce and tomato salad, stir-fried vegetables, and a grilled cheese sandwich, none of which were appropriate for the resident’s ordered diet. The Registered Dietitian and the Dietetic Technician confirmed that Daily Menu printouts with Regular Menu options were provided to all residents, including those on mechanically altered diets, resulting in residents being offered choices that could not be honored due to diet restrictions. Another resident with moderate cognitive impairment had a physician order for a mechanical soft diet with nectar-thick liquids. This resident’s lunch tray ticket was also stapled to a Regular Menu that included salad greens, which are not allowed on a mechanical soft diet. On a separate breakfast observation, the same resident’s Regular Menu included fresh fruit as a choice, which the resident circled, but the tray contained canned peach halves instead. The resident stated she wanted her chosen fresh fruit rather than the peaches and reiterated her food preferences during the interview. Photographic evidence was obtained to document these discrepancies between ordered diets, menu offerings, and the food actually provided.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is requiredF05501. Resident #54 and Resident #56 were immediately assessed by the Registered Dietitian (RD) & CDM (Certified Dietary Manager) for food preferences on Residents #54 and #56 were offered meal choices consistent with the prescribed diet. No adverse outcomes were identified. 2. 100% audit of all residents with therapeutic diets was completed on [R] by CDM to ensure menus and meal selections consistent with physician-ordered diets.On [R] , CDM provided in-service provided to dietary aides, certified nursing assistants, nurses, managers on new selective menu processes. 3. The facility implemented a diet-specific menu system and pre-meal diet verification process by reviewing the diet in tray ticket program IMPAC and PCC. Copies of the menus to be provided as part of the audits.Diet Menu was revised to include a mechanically altered diet to be consistent with physician orders. Therapeutic diets menus are available and offered to each resident according to physician orders. The Dietary Manager or designee will conduct weekly audits of 4 residents on therapeutic diets x 4 weeks then monthly x 2months, to verify the correct menu is offered and served. 4. The Dietary Manager or designee will report findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R] , and resolving any variances that occur.
Resident Dignity Compromised During Transport in Geriatric Chair
Penalty
Summary
The deficiency involves a failure to maintain a resident’s dignity and right to a dignified existence and self-determination when a nurse aide transported the resident in a manner inconsistent with facility expectations. The resident, who had clear speech but severe cognitive impairment and required a wheelchair for mobility, was observed during a continuous observation being quickly pulled backward approximately 30 feet down the South Hall from the day room to her room while reclined in a geriatric chair. A reasonable person would have expected to be treated with dignity and to be wheeled forward in the chair. During interviews, the nurse aide stated he chose to pull the resident backward because he felt it was harder to push the reclined geriatric chair forward and reported no awareness of problems with the chair. The social worker later pushed the same geriatric chair forward and backward in the hallway and noted no functional concerns, stating the chair worked fine and needed no repairs. The Staff Development Director reported that staff receive education on residents’ rights, dignity, and wheelchair use, including speed and footrest use, and acknowledged the resident should not have been pulled backward in the geriatric chair. The DON and Administrator both stated they expected staff to push residents in wheelchairs and geriatric chairs forward, at a normal pace, and in a dignified manner.
Failure to Provide Dignified, Responsive Care and Respect Resident Rights
Penalty
Summary
The deficiency involves the facility’s failure to provide care in an atmosphere of dignity and respect and to protect residents’ rights to be free from neglect, interference, and dismissal of their needs. A facility document outlining resident rights states that residents must be treated with dignity and respect, be able to make their own schedules, and be free from abuse and neglect. A letter signed by nine residents reported that aides and other employees were frequently on their cell phones or wearing earbuds, talking, eating, watching videos, or listening to music instead of working. The letter described residents being left in the dining room until late in the evening while aides sat in breakrooms on their phones, residents not being fed, being left in dirty briefs for hours, waiting hours to be transferred from wheelchairs to beds, staff carrying hot plates in one hand and cell phones in the other while residents waited, and aides vaping in hallways and in the employee bathroom. During a resident group interview, 13 of 14 residents reported that staff ignored their care needs, turned off call lights without providing care, and that when concerns were brought to administration, they were told “We will look into it,” but residents stated this did not occur. Residents reported staff using phones while providing care, widespread delays in assistance getting in and out of bed, and feeling dismissed, dehumanized, and fearful of retaliation if they filed complaints. Individual residents described specific incidents: one resident reported waiting until late at night to be put to bed after being placed in a chair in the morning, despite ringing for help for a long time, and feeling completely ignored and “like a table.” Another resident reported being left on a bedpan through dinner after staff refused to assist, and another stated they were left sitting in urine and feces for about eight hours, developing a rash and being inadequately cleaned, with cream applied repeatedly without proper washing. Additional interviews reinforced these concerns. One resident reported having to call a family member to get staff to respond after being left in a room with the door shut, waiting an hour to an hour and a half for assistance. Another resident stated that staff would answer the call light, say they would return, and then never come back. A resident reported that during a meeting with the Administrator, the focus was on profit rather than patient care. Several residents described feeling that staff did not care about them, being rushed during care, being cleaned with a pillowcase due to lack of washcloths, and being left in soiled briefs long enough to cause skin irritation. One resident, who stated she was not incontinent, reported repeatedly waiting a long time for help to use the bedpan, not always receiving fresh water, and seeing staff walk by without entering her room, leading her to feel ignored and unworthy. The Nursing Home Administrator confirmed that the facility failed to provide services in an atmosphere of dignity and respect for multiple residents identified in the survey.
Plan Of Correction
Resident R9 is no longer in the facility. The social worker interviewed R21, R26, R63, R64, and R86. Any voiced concerns will be investigated without fear of retaliation. The social worker will document the follow-up of these investigations in the appropriate location The administrator requested that she attend the resident council meeting regularly. Will review with each current resident their preferred time to get out of bed and return to bed. This will be documented in the nurse aide documentation system and care planned. The social worker and the administrator will interview the current resident population to address any areas of concern or complaints. Resident interviews/satisfaction surveys/follow-up resident council interview will be completed to ascertain if the changes made have improved the life of the residents related to care. We will interview Five residents a week for four weeks and then monthly ongoing The staff have been educated on timely completion of ADL and incontinent care per care plan, The facility staff will be educated on the cell phone/earbud policy: they are not permitted in resident care areas. And that No Vaping is allowed in the facility. Signs indicating No Vaping have been posted at the front and back entrances. Facility Staff will be educated on the Call light policy and their requirement to assist answering call lights to their level of ability. Sensitivity training will be completed with the Nursing staff. Agency staff will also be required to view this training. Audits for the Cellphone/Earbud policy, Vaping, and call light response times will be completed by the DON/Designee four times weekly two audits per shift and monthly times three, with two audits per shift. occurring on varying units and times of the day.
Failure to Maintain Resident Dignity When Clothing Did Not Fit Properly
Penalty
Summary
The deficiency involves the facility’s failure to maintain resident dignity by allowing a male resident’s pants to repeatedly fall and expose his buttocks in common areas without effective intervention. On one observed occasion during meal service at 11:55 AM, the resident stood up from the dining table and, as he began to walk, his pants fell below his abdomen, exposing the top of his buttocks. The resident had to grab the waistband of his pants to hold them up, and another elderly female resident verbally remarked that she had seen his buttocks. On another observed occasion at 12:10 PM, the same resident was at the nurse’s station on the phone when his plaid pajama pants slipped below his abdomen, exposing approximately a quarter of his buttocks. As he walked to the dining room, he continued to pull up his pants in an attempt to keep them from falling. During an interview on 06/08/26 at 11:00 AM, a licensed nurse stated that the resident had not experienced weight loss and she did not know why his clothes were not fitting correctly. The facility’s policy on Respect and Dignity, Right to Personal Property, Including Searches and Illegal Substances, dated 06/25, states that residents have the right to be treated with respect and dignity and that staff shall provide person-centered care emphasizing residents’ comfort, independence, and personal needs and preferences, including accommodation of personal clothing unless it infringes on others’ rights or safety. The repeated exposure of the resident’s buttocks in public areas, observed by other residents, occurred despite this policy and constituted a failure to promote and protect the resident’s dignity.
Failure to Provide a Dignified Dining Experience During Assisted Feeding
Penalty
Summary
The facility failed to provide a dignified dining experience for one of three observed residents when the Director of Nursing (DON) fed the resident while standing. The resident, identified as R81, had been admitted earlier in the month and had documented diagnoses including stroke, dementia, and high blood pressure, as recorded on the MDS dated 2/28/26. On 3/30/26 at 12:05 p.m., surveyors observed Resident R81 seated in a wheelchair in the main dining room being fed by the DON, who remained standing during the feeding interaction. During an interview at 12:06 p.m. on the same day, the DON confirmed that they were not in a seated position while feeding the resident, as required, thereby acknowledging that the facility did not provide a dignified dining experience for this resident. This conduct was cited as noncompliance with 28 Pa. Code 211.10(a)(c)(d) regarding resident care policies and 28 Pa. Code 211.12(d)(1)(2)(5) regarding nursing services.
Failure to Maintain Resident Dignity During Personal Care and Catheter Management
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were treated with dignity and respect in accordance with its Dignity policy dated 9/12/25, which states that each resident has the right to be treated with dignity and respect and specifies avoiding demeaning practices such as leaving urinary catheter bags uncovered. For one resident with diabetes and a need for assistance with personal care, a CNA removed the resident’s shirt without pulling the privacy curtain, even though the resident’s roommate was present in the room and able to observe the undressing. The resident later stated she usually pulls the curtain so her roommate cannot see her being changed but had forgotten on this occasion, and the CNA acknowledged she should have provided privacy before removing the shirt. For another resident with multiple diagnoses including enterocolitis due to Clostridium difficile and COPD, surveyors observed from the hallway that the resident’s urinary catheter bag was hanging on the side of the bed without a privacy bag or cover, with the room door open and the bag visible from the hallway. Nursing staff later stated the catheter bag had not been covered because the resident had just returned to the room and that the CNA must have forgotten to cover it. The CNO confirmed that the catheter bag should have been covered or placed in a privacy bag and that it had not been, contrary to the facility’s policy on promoting resident dignity.
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