Failure to Honor DNR Order Resulting in Unwanted CPR and Resident Harm
Summary
The facility failed to honor a resident's Do Not Resuscitate (DNR) advanced directive, resulting in staff performing cardiopulmonary resuscitation (CPR) on a resident who had a clearly documented DNR order. The resident had multiple signed state DNR forms in the electronic medical record, an active medical doctor order for DNR, and a care plan indicating DNR status. The resident was also wearing a DNR bracelet at the time of the incident. Despite these clear indications, when the resident became unresponsive and pulseless, the registered nurse on duty initiated CPR without verifying the resident's code status. The nurse reported being unable to ascertain the resident's code status at the time of the emergency, stating that the only way to check would have been to leave the resident alone to access a computer. The nurse did not notice the DNR bracelet on the resident's wrist before starting compressions and was not aware of a process for calling a code or obtaining assistance to verify code status. Other staff members confirmed that the resident's DNR status was documented in the electronic medical record and that the resident wore a DNR bracelet. The nurse performed between 12 and 16 chest compressions, which resulted in the resident being revived. Following the administration of CPR, the resident experienced extreme pain, particularly in the chest and ribs, requiring narcotic pain medication for management. The pain persisted until the resident's death. Documentation showed that the resident's pain was rated as high as 10 out of 10, and the resident required both as-needed and scheduled morphine. The incident was identified as immediate jeopardy due to the facility's failure to follow the resident's advanced directive, resulting in unnecessary resuscitation and significant pain.
Removal Plan
- Primary Care Physician, Hospice MD, and POA notified.
- Hospice in person visit.
- Skin evaluation.
- Pain evaluation.
- Change of Condition evaluation with vital signs.
- Nursing evaluation.
- Morphine as needed ordered.
- Current residents reviewed for code status orders/documentation.
- Code status verified on PCC ribbon banner.
- Care plans updated appropriately.
- Reeducation to licensed nurses on need to verify code status prior to initiating CPR.
- If DNR-do not initiate CPR.
- If full code, initiate CPR and activate 911.
- DON/designee will conduct Code drills on each shift.
- Interviews of nurses will be conducted on various shifts using case studies and 'what if' scenarios to validate understanding and expectations required during a code situation.
- Scenarios will include situations where resident is a DNR, and others where resident is a full code.
- Results of the above audits will be brought to the Quality Assurance and Performance Improvement (QAPI) committee.
- QAPI committee met to review above plan.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with chronic respiratory failure, tracheostomy, schizophrenia, and severely impaired cognition had an existing court-supported advance directive and DNR, documented in the EMR and signed by the guardian and a physician. During a mock survey, regional staff reportedly told facility staff the DNR was not valid because it was signed after guardianship paperwork, and the then-DON had the provider discontinue the DNR and change the resident’s status to full code. Subsequent provider orders and the care plan directed CPR and full-code measures, while notes and interviews showed staff confusion about the DNR’s validity and no follow-through by social services to assist the guardian in re-establishing the DNR, contrary to facility policy requiring that advance directives be respected and clearly documented.
The facility failed to assist a resident in exercising the right to formulate an advance directive. A resident with quadriplegia and depression had a POST form in the medical record but no documented advance directive and no documentation that the facility informed the resident or provided written information about the right to create one. The Administrator confirmed that only POST documents were on file for this resident, with no evidence of required advance directive information being provided.
Surveyors found that the facility failed to provide required information about advance directives to a resident’s representative and did not obtain or maintain copies of advance directives for two residents. One cognitively impaired resident was care planned as full code without any documented discussion or written information about advance directives provided to the representative. For another resident, the responsible party repeatedly reported that an advance directive existed and confirmed full code status, but staff did not consistently follow up to obtain the document, and no advance directive was filed in the medical record despite multiple care plan meetings and psychosocial assessments noting its existence.
A resident with severe cognitive impairment, multiple complex medical conditions, and a POLST directing provision of artificial nutrition and hydration via surgically placed tubes was care planned as NPO with enteral feeding for all nutrition needs, yet had no active tube feeding orders and was observed on multiple occasions without any feeding infusing. An RN reported that hospice had discontinued the feeding, the POA stated she had been told feeding could not be restarted despite wanting it continued, and the DON was unaware the feeding had been stopped. The MD acknowledged hospice stopped the feeding due to aspiration risk and stated that the POLST should be revised if G-tube feeding is discontinued, while facility policy affirms residents’ rights to determine life-sustaining treatments, including artificial hydration and nutrition.
A resident with intact cognition and multiple cardiac and pulmonary diagnoses had clearly documented DNR orders, including signed advance directive forms and care plan entries confirming her wish to avoid resuscitation. During a cardiac emergency, a CNA found the resident unresponsive and notified an RN, who initiated a code blue response. Several RNs and LPNs transferred the resident to bed and began CPR without first verifying code status, despite one LPN asking and then leaving the room to check the record. Staff interviews and video review showed that chest compressions and use of a bag-valve mask continued for about 12 minutes until EMS arrived, even after staff learned the resident was DNR, and the physician confirmed the resident was already listed as DNR in the system, leading to an Immediate Jeopardy finding for failure to honor advance directives.
A resident with multiple neurologic and respiratory diagnoses and moderate cognitive impairment had a documented change in code status from full code to DNR, with a care plan and physician order reflecting DNR status. An OOH-DNR form was completed and signed by the resident’s representative and two witnesses, but the attending physician did not sign the form as required by the OOH-DNR instructions and the facility’s advance directive policy. Facility staff, including SS, the DON, and the Administrator, acknowledged the missing physician signature yet indicated the DNR would still be honored in-house, resulting in a deficiency related to improper completion of the OOH-DNR.
Failure to Honor a Resident’s Existing DNR and Advance Directive
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s existing do not resuscitate (DNR) order and advance directive. The resident had chronic respiratory failure, a tracheostomy, schizophrenia, severely impaired cognition, and required total assistance with all activities of daily living. The resident was nonverbal, rarely communicated, and was dependent on staff for all care. Court documentation under Kansas law authorized the guardian and conservator to consent on the resident’s behalf to the withholding of life-saving medical care, treatment, services, or procedures. The resident’s electronic medical record contained an uploaded DNR document signed by one physician, the guardian, and two witnesses, and the physician orders initially documented a DNR status from admission. Despite this, the resident’s DNR order was discontinued on a later date and replaced with a physician order for full code, all measures. The care plan was updated to instruct staff to initiate CPR when appropriate and continue until paramedics arrived. Provider notes showed conflicting documentation, with one note listing the code status as DNR and a later note documenting that the DON notified the provider that the resident required a DNR form in the chart. The provider then ordered the resident to be full code until two physicians could sign a form stating the resident was a DNR candidate and the durable power of attorney would work through the court process, and a progress note recorded that the code status was updated to full code pending completion of this process. Interviews and record reviews revealed confusion among staff regarding the validity of the DNR and the impact of guardianship paperwork. The social services designee reported that during a mock survey by regional staff, she was told the resident’s DNR was not valid because it was signed after the guardianship paperwork was in effect, and that the then-DON had the provider discontinue the DNR. She also stated she had not spoken with the guardian about a request for assistance in completing a DNR. The guardian reported that the resident used to be a DNR, that an audit required a change to full code, and that he did not understand why and had asked the facility for assistance. Administrative staff later reviewed the EMR, DNR, progress notes, orders, and guardianship paperwork and stated they had no prior knowledge of the guardian’s concern, even though facility policy required that advance directives be respected and prominently displayed in the medical record.
Failure to Assist Resident in Formulating an Advance Directive
Penalty
Summary
The facility failed to ensure a resident and their representative received assistance to exercise the right to formulate an advance directive. Record review showed that one resident, admitted with multiple diagnoses including quadriplegia and depression, had a Physician Orders for Scope of Treatment (POST) form in the medical record but no documented advance directive. The record also lacked documentation that the facility had informed the resident or provided written information about the right to formulate an advance directive. During interview, the Administrator stated that the facility only had POST documents for this resident, confirming the absence of advance directive documentation or evidence of required information being provided. This deficient practice created the potential for harm or adverse outcomes if the resident’s wishes were not followed or documented regarding their advance care planning.
Failure to Provide Information and Maintain Documentation of Advance Directives
Penalty
Summary
The deficiency involves the facility’s failure to provide required information about advance directives and to obtain and maintain documentation of residents’ advance directives in the medical record. For one resident admitted on an unspecified date, the admission MDS showed severe cognitive impairment, and the care plan dated 1/26/26 listed the resident as full code. However, there was no documentation in the record that the resident’s representative had been provided written information about the right to refuse medical or surgical treatment or to formulate an advance directive. The resident’s representative reported that no facility representative had discussed any information regarding an advance directive, and the social worker confirmed she had been on leave at the time of admission and indicated it would have been the previous social worker’s responsibility to address advance directives. For a second resident, multiple care plan notes and psychosocial discharge planning assessments documented that the responsible party reported the resident had an advance directive and confirmed full code status, and that guardianship paperwork would be brought in. Despite this, there was no documentation that the social worker requested or obtained a copy of the advance directive beyond the initial conversation, and subsequent care plan notes did not reflect follow-up requests. The psychosocial assessments repeatedly recorded that the resident was assessed to have an advance directive per the responsible party, but the medical record contained no copy of the advance directive. Interviews with social work staff and the administrator confirmed that the facility’s practice was to discuss advance directives upon admission, determine whether an advance directive existed, and request a copy for the medical record, with follow-up at subsequent care conferences if the document was not initially provided. In the case of the second resident, the current social worker acknowledged that the responsible party had not brought in the advance directive and that she did not follow up, and the prior social worker stated she believed she had not followed up due to difficulty reaching the responsible party. The administrator stated she expected social workers to discuss advance directives within three days of admission and to obtain and maintain copies in the medical record, which did not occur for these two residents.
Failure to Follow POLST Regarding Artificial Nutrition and Hydration
Penalty
Summary
The facility failed to follow a resident’s advance directive, specifically the Illinois POLST form, regarding the provision of artificial nutrition and hydration. The resident, who had anoxic brain damage, severe protein-calorie malnutrition, acute and chronic respiratory failure, a stage 4 sacral pressure ulcer, tracheostomy and gastrostomy status, and a history of sudden cardiac arrest, was cognitively severely impaired and dependent on staff for all ADLs. The POLST form directed that artificial nutrition and hydration be provided by any means, including new or existing surgically placed tubes. The resident’s care plan documented NPO status with enteral feeding for all nutrition needs, with interventions to adjust tube feeding as needed and monitor tolerance, weight, labs, skin, and hydration. However, record review showed that the resident had no active G-tube feeding orders, only water flushes and medications, and that a prior continuous tube feeding order had been discontinued on a specified date. During observations on two separate days, the resident was seen in bed, unresponsive to questions, with a G-tube plunger at the bedside but no feeding pump or feeding infusing. When questioned, an RN stated she was unsure of the feeding orders and later reported that hospice had discontinued the feeding. The resident’s family member/POA reported being told by hospice that feeding could not be restarted because the resident was at end of life and, lacking clinical experience, accepted this explanation, although she stated she wanted the resident to continue receiving feeding. The DON stated she was unaware that the feeding had been discontinued and affirmed that the facility should follow the POLST. The physician acknowledged knowing that hospice had stopped the feeding due to aspiration risk and that the resident’s wife was said to be okay with it, and further stated that if G-tube feeding is discontinued, the POLST should be readdressed and a new one obtained. The facility’s advance directive/DNR policy states that residents have the right to determine in advance what life-sustaining treatment will be provided, including artificial hydration and nutrition, and that such directions enable staff to know how to treat residents in advance of an emergency.
Failure to Verify and Honor DNR Order Before Initiating CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s clearly established Do Not Resuscitate (DNR) status during a cardiac emergency. The resident had multiple medical diagnoses, including cerebral infarction, COPD, cardiomyopathy, atherosclerotic heart disease, a nonrheumatic mitral valve disorder, cognitive communication deficit, and immunodeficiency. The medical record contained DNR orders created on two separate dates with no end dates, a DNR document signed by the resident and a nurse practitioner, and a 3008 form listing the resident’s advance directive as DNR. The resident’s MDS showed a Brief Interview for Mental Status score of 15, indicating intact cognition, and progress notes documented that the difference between DNR/no CPR and full code had been explained over 30 minutes, after which the resident chose DNR and reiterated to social services that she did not want to be resuscitated or undergo chest compressions. On the day of the incident, a CNA assigned to the resident checked on her and found her sitting in a wheelchair and unresponsive despite multiple verbal attempts to rouse her. The CNA notified the RN, who obtained a blood pressure machine, entered the room, then ran out to the nurses’ station, after which a code blue was paged over the intercom. The RN returned with a crash cart, and additional nursing staff, including RNs and LPNs, entered the room. Staff described transferring the unresponsive resident from the wheelchair to the bed and beginning chest compressions. Multiple staff members reported that when one LPN asked about the resident’s code status, no one in the room knew it at that time, and that this LPN left the room to verify the code status while CPR was already in progress. Interviews and video review confirmed that CPR was initiated and continued for approximately 12 minutes before EMS arrived, despite the resident’s existing DNR orders. Several nurses, including those who arrived after CPR had started, acknowledged that they did not check the resident’s code status before assisting with chest compressions or using a bag-valve mask. Staff later reported that the LPN who checked the record returned and announced that the resident was a DNR, yet compressions continued until EMS arrived. The physician stated that the resident was already in the system as a DNR and that staff were expected to check code status before performing CPR. The DON and regional nurse consultant confirmed, based on interviews and camera review, that staff failed to confirm the resident’s code status prior to initiating CPR and that CPR was performed against the resident’s wishes, leading surveyors to determine that this failure resulted in Immediate Jeopardy.
Removal Plan
- Implemented a revised admission/readmission process requiring an Advance Directive discussion form to be completed by the licensed nurse upon admission or with change in advance directives, with follow-up by Social Services.
- Reviewed Advance Directive discussion forms in the daily clinical meeting with the Interdisciplinary Team.
- Conducted a huddle on units after the clinical meeting to discuss any changes in advance directives/code status.
- Placed signage on each crash cart stating: "Stop check physician order prior to starting Cardiopulmonary Resuscitation."
- Implemented the "It Takes Two" process requiring two licensed nurses to verify code status/advance directives prior to initiation of CPR.
- Initiated an internal investigation including resident record review, staff interviews, and notification to the physician and resident representative.
- Suspended and terminated the assigned nurse and reported the nurse’s license to the licensing board.
- Suspended and terminated an additional nurse who responded and participated in initiation of CPR and reported the nurse’s license to the licensing board.
- Suspended two additional nurses pending investigation and returned them to work with disciplinary action, education on ANE/honoring advance directives, and participation in a code blue drill.
- Conducted a 100% audit of all current residents’ code status and care plans.
- Conducted a 100% audit of crash carts to ensure all required items were present.
- Reviewed CPR cards for identified nurses to confirm validity and inclusion of in-person skills competencies.
- Held an ad hoc QAPI meeting with Administrator, DON, Medical Director, and department heads.
- Completed an audit of residents discharged, transferred to the hospital, or expired to verify advance directives were honored.
- Provided staff education for licensed/certified staff on medical emergency response and communication of advance directives and code status, following physician orders related to advance directives, the "It Takes Two" verification process, and CNA roles during code blue.
- Provided all-staff education on Abuse, Neglect and Exploitation/Resident Rights with focus on honoring advance directives.
- Completed honoring advance directives attestation with licensed nursing staff.
- Completed physician orders education for licensed nursing staff.
- Completed medical emergency response and communication of code status education for licensed nursing staff.
- Completed ANE/Resident Rights education for all staff.
- Completed advance directives posttest for licensed staff.
- Completed ANE/Resident Rights posttest for all staff.
- Completed code blue process/"It Takes Two" education for licensed nursing staff.
- Began code blue drills every shift and required licensed nurses to attend a mock code blue quality assurance drill prior to working.
- Completed CNA roles-in-code-blue training.
- Completed quality reviews validating staff competencies for completed education.
- Completed quality reviews of newly admitted residents to verify completion of the advance directive discussion form.
- Implemented Director of Clinical Services chart review of residents who expire at the facility or are transferred to the hospital after a cardiac event to verify advance directives were followed.
Failure to Obtain Physician Signature on OOH-DNR Order
Penalty
Summary
The facility failed to ensure a resident’s right to formulate and implement an advance directive by not obtaining the physician’s signature on an Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) order. The resident was an older female with diagnoses including nontraumatic intracerebral hemorrhage in the cortical hemisphere, other toxic encephalopathy, pneumonia due to inhalation of food and vomit, and Wernicke’s encephalopathy. Her Quarterly MDS showed a BIMS score of 09, indicating moderate cognitive impairment, with unclear speech and intermittent ability to understand and be understood. The comprehensive care plan identified the resident as DNR, initiated and revised on the same date, and a progress note documented that the resident’s representative requested a change from full code to DNR. The order summary also reflected a DNR order. The OOH-DNR form for this resident, dated the same day as the DNR order, contained the signatures of the resident’s representative and two witnesses but lacked the attending physician’s signature, as required by the OOH-DNR instructions and the facility’s policy on residents’ rights regarding treatment and advance directives. During interviews, the social services staff member, the DON, and the Administrator each acknowledged that the physician had not signed the OOH-DNR at the time, yet stated that the DNR would be honored in-house if an event occurred. The OOH-DNR instructions specified that the attending physician must sign the form and document the existence of the order in the permanent medical record, and that the order must be signed and dated by two witnesses and, when applicable, by the physician in the designated section. The absence of the physician’s signature on the OOH-DNR constituted the deficiency.
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