Failure to Honor Advance Directive and DNR Order
Penalty
Summary
Facility staff failed to honor a resident's advance directive and physician's Do Not Resuscitate (DNR) order. The resident, who had diagnoses including cerebral infarction, endocarditis, hypertensive heart disease, and ulcerative colitis, was documented as having intact cognitive skills and had executed an advance directive indicating a wish not to prolong life. The resident's medical record included a DNR order, and the facility had acknowledged receipt of the advance directive. Despite these clear instructions, the resident received cardiopulmonary resuscitation (CPR) after being found on the floor by staff. Interviews with the family member and the Director of Nursing confirmed that CPR was administered against the resident's documented wishes and medical orders. The facility's policies required adherence to advance directives and DNR orders, but these were not followed in this instance. The Director of Nursing acknowledged that CPR should not have been performed, as it was contrary to both the resident's advance directive and the physician's order.