DNR Order Not Honored Due to Delayed Code Status Verification
Penalty
Summary
A deficiency occurred when a resident with a documented Do Not Resuscitate (DNR) order received cardiopulmonary resuscitation (CPR) from facility staff. The resident had a clearly documented DNR order, signed by both the resident and the attending physician, indicating that no resuscitation should be attempted in the event of cardiac or respiratory arrest. On the day of the incident, the resident became unresponsive and staff could not detect a pulse after a transfer using a hoyer lift. A Licensed Practical Nurse (LPN) responded to calls for help and, unable to immediately confirm the resident's code status, initiated CPR. The LPN reported that she began compressions because staff were unable to quickly provide the resident's code status, and she acted as she would in a situation where code status was unknown. Approximately 45 seconds of compressions were performed before other staff confirmed the DNR status, at which point CPR was stopped. The resident subsequently regained a pulse and began breathing again. Interviews with staff revealed that the process for verifying code status was not efficient, as the information was only available in the computer and not readily accessible during emergencies. The Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed that CPR was performed on a resident with a DNR order and that no incident report or immediate follow-up education was completed after the event. The facility's policy required staff to validate code status before initiating CPR, but this was not followed due to delays in accessing the information.