Failure to Honor Resident's DNR Order During Emergency Transfer
Penalty
Summary
The facility failed to honor a resident's advance directive regarding Do Not Resuscitate (DNR) status. The resident, who was cognitively intact and had multiple significant diagnoses including chronic obstructive pulmonary disease, congestive heart failure, and acute respiratory failure, had a clearly documented DNR order in the medical record. The DNR status was supported by both physician orders and a signed LaPOST form, and the resident's care plan reflected the DNR status. During an episode of respiratory distress, nursing staff responded by increasing oxygen and attempting a breathing treatment. When the resident did not improve, 911 was called. Upon arrival, EMS initiated CPR, despite the resident's DNR status. Both the RN and LPN present at the time confirmed in interviews that they did not inform EMS of the resident's DNR order. The LPN specifically stated that in the haste to transfer the resident to the hospital, she did not check the code status and acknowledged that she should have done so. The facility's policies required that advance directives be readily accessible in the medical record, that staff communicate code status to EMS, and that residents' wishes be honored. However, these procedures were not followed during the incident, resulting in the resident receiving resuscitation efforts contrary to her documented wishes and advance directives.