Failure to Honor Resident DNR Status Results in Unwanted CPR
Summary
Staff failed to honor a resident's documented choice to be a Do Not Resuscitate (DNR) when they initiated cardiopulmonary resuscitation (CPR) after the resident was found unresponsive and not breathing. The resident had a completed and signed Outside the Hospital Do Not Resuscitate (OHDNR) order, which was available in both the resident's medical record and a binder at the nurse's station. Despite these measures, the nurse on duty was unable to immediately locate the DNR paperwork in the binder and, based on the information available at the time, instructed staff to begin CPR and called 911. The nurse later accessed the electronic health record (EHR) and confirmed the resident's DNR status, but CPR had already been initiated and was not stopped. Emergency medical services (EMS) arrived, obtained a faint pulse, and transported the resident to the hospital, where the resident was pronounced dead on arrival. Interviews with staff revealed that code status information was accessible in multiple locations, including the EHR, crash cart clipboards, and binders at the nurse's station, and that it was the responsibility of the nurse to verify code status prior to initiating CPR. The incident occurred despite facility policies requiring verification of code status before starting CPR and the presence of systems intended to communicate residents' code status to direct care staff. The failure to promptly locate and confirm the resident's DNR status resulted in the initiation of life-prolonging measures that were contrary to the resident's documented wishes.
Penalty
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A resident with moderate cognition and a history of smoking repeatedly expressed a desire to smoke, but staff told her she could not because the campus was smoke-free. Her care plan did not address smoking, no updated smoking assessment was completed after she voiced her preference, and the IDT did not document discussion of options to accommodate off-campus smoking despite the facility policy calling for individualized assessment and consideration of safe smoking practices.
A cognitively intact resident with multiple chronic conditions, including anxiety, depression, and insomnia, repeatedly reported that staff propped her room door open with a trash can at night, leaving light and noise in the room and preventing sleep. She asked for the door to be kept shut, but aides continued opening it, and a CNA confirmed the practice was done because of the roommate’s condition despite the resident’s objections.
Failure to Provide Requested Socks: A resident with intact cognition and diagnoses including HF and type II DM was observed barefoot in his wheelchair and while walking in the hallway and on the elevator after asking staff multiple times for socks. Staff acknowledged that residents should not be barefoot in common areas and stated gripper socks were available, but the resident was still left without socks.
Resident self-determination was not supported when a resident’s self-purchased coffee maker was removed from his room and stored in his closet after the NHA learned he was using it. The resident said he wanted his own coffee, but staff reported no alternate arrangement was made and he was only given facility coffee. The NHA said the restriction was based on a prior survey issue involving a coffee maker and extension cord, even though survey review found no safety concern for the resident’s coffee maker in the room.
Resident Bathing Preferences Not Met: A resident with MS and DM had no cognitive deficit and was dependent for bathing, but her documented shower preference was not fully captured or followed. Staff only recorded shower versus bath preference, did not document how many showers she wanted, and the POC lacked refusal documentation even though the resident reported she was no longer receiving the 3 showers per week she had previously gotten.
A facility gave conflicting and inaccurate information about smoking during admission, with the ADM saying it was non-smoking while the admission packet and written policy indicated residents had smoking rights and designated smoking areas. The DON stated the facility was not providing accurate smoking information and was not following its own policy. The facility also failed to honor a blind resident's stated preference for a Sunday bed bath; instead, a CNA brought the resident to the bathroom sink and gave towels for self-care, despite the care plan and posted instructions indicating a bed bath was to be provided.
Failure to Support Resident Smoking Preference
Penalty
Summary
The facility failed to support a resident’s expressed choice regarding smoking for 1 resident who had moderate cognition and was able to make her needs known. The resident’s diagnoses included dementia, anxiety, depression, and diabetes. Her smoking risk assessment noted a history of smoking but stated she did not plan to smoke during her stay, and her care plan did not address a smoking preference. However, progress notes documented that she told the LSW on two occasions that she wanted to go outside and have a cigarette and that she missed smoking and wished she could still smoke. The facility did not document an assessment of the resident’s ability to smoke safely off campus after she expressed interest in smoking, and the care conference note did not identify any discussion of her desire to smoke. During a resident council meeting, the resident stated she wanted to smoke but was told by staff that she could not. The LSW stated the resident requested smoking on two occasions, but follow-up discussions with the IDT were not documented and the IDT did not evaluate options to accommodate her preference. The RN stated residents with a smoking history were assessed on admission, but no smoking assessment had been completed since admission for this resident. The facility maintained a blanket practice prohibiting smoking by new residents, while its policy stated residents who wished to smoke were to be assessed for safe smoking practices and ability to smoke independently off campus.
Resident’s Room Door Left Open Despite Request for Privacy and Sleep
Penalty
Summary
The facility failed to honor a resident’s choices regarding her room environment and sleep preferences. Resident #19, who was cognitively intact and had diagnoses including hypocalcemia, type II diabetes mellitus, anxiety disorder, depression, hypothyroidism, adjustment disorder with mixed anxiety and depressed mood, paranoid personality disorder, malignant neoplasm of the thyroid gland, and mild neurocognitive disorder, repeatedly documented that staff opened her room door and propped it open with the roommate’s trash can, which let in a great amount of light and interfered with her sleep. Her written statements noted that ear plugs did not help, that she had sleep disorders, and that the light and noise from nighttime staff prevented her from sleeping and caused her eyes to hurt from lack of sleep. The resident told staff she wanted the door shut tightly at night, but she reported that aides did not respect her request and continued to leave it open. During interview, she stated the door had been propped open for months and that she would close it herself only for staff to reopen it shortly afterward. Observation confirmed the door was propped open with a garbage can, and CNA #355 acknowledged propping the door open because of the roommate’s condition. RN #398 also verified the resident had complained about not sleeping well because the room door was being propped open. The facility’s Resident Rights policy stated residents had the right, upon reasonable request, to have room doors closed and not opened without knocking except in emergencies or when medically inadvisable as documented by the attending physician.
Failure to Provide Requested Socks
Penalty
Summary
The facility failed to provide appropriate socks to a resident who requested them. The resident’s quarterly MDS indicated intact cognition and diagnoses of heart failure and type II diabetes. During observation, the resident was found barefoot in his wheelchair in his room and stated he had asked staff several times for socks and had not received any. Staff later observed the resident barefoot again while sitting in his wheelchair, and he was also barefoot when walking in the hallway and going to the elevator with PT. Multiple staff members acknowledged that the resident should not have been barefoot in the hallway or on the elevator and stated that socks, including gripper socks, were available in the facility. An NA told the resident he would have to wait for socks from laundry, and an LPN noted that the resident still had not been found socks. Staff interviews confirmed that residents should be wearing socks, especially when ambulating in common areas, and the DON stated this was important because the resident was diabetic and more susceptible to wounds and skin alterations. The facility did not have a policy addressing the concern.
Resident Choice Not Supported for In-Room Coffee Maker
Penalty
Summary
The facility did not promote and facilitate resident self-determination through support of resident choice for one sampled resident who wanted to keep a self-purchased coffee maker in his room. The resident reported that he bought his own coffee maker, but the facility told him he could not have it in his room and required him to place it back in the original box and store it in his cupboard. He stated that he wanted his own coffee because the facility coffee “sucks.” Survey observation confirmed the coffee maker was in an opened box on the top shelf of the resident’s closet. Staff interviews showed the resident had used the coffee maker in his room for about a week and a half before the NHA found out and removed it. The CNA reported that no other arrangements had been made to allow the resident to have coffee of his choice, and that he was only being given facility coffee. The NHA stated the restriction was based on a prior survey citation involving a coffee maker and a power extension cord, and said the facility did not allow any residents to have coffee makers because of that concern, even though survey review found no safety concern for this resident’s coffee maker in the room.
Resident Bathing Preferences Not Met
Penalty
Summary
The facility failed to ensure a resident's bathing preferences were met for one resident reviewed for choices. The resident stated that she used to receive 3 showers per week until she began needing a shower chair, and then she was only getting 2 showers per week if she was lucky. Her record showed diagnoses including multiple sclerosis and diabetes mellitus with hyperglycemia, and an annual MDS indicated she had no cognitive deficit, no documented refusal behaviors, and was dependent for personal hygiene and bathing. Her annual Life Enrichment assessment documented that she preferred showers, but it did not state how many showers per week she preferred. The resident's care plan identified that she preferred showers and directed staff to shower her per schedule, but it did not document refusals related to ADL assistance. Review of the POC for April and May 2026 showed showers were provided on several dates, but there was no documentation of any resident refusals of care. The ADNS stated staff did not complete shower sheets and that the POC was used to document showers, baths, and refusals. The Life Enrichment Director stated she only asked residents whether they preferred a shower or bath and had not asked how many showers they preferred, while the Regional Clinical Support stated there was no specific policy for the number of showers but staff would attempt to ensure residents received 2 showers per week and could not find documentation of the resident's refusals.
Inaccurate Smoking Information and Failure to Honor Resident Bathing Preference
Penalty
Summary
The facility failed to provide residents with accurate information needed to make informed choices about smoking preferences and failed to follow its own smoking-related policies. During interviews, the Administrator stated the facility had been non-smoking since 2010 and that residents and families were told this before admission. However, the admission Coordinator reviewed the admission packet and found a Smoking Policy and Guidelines section stating the facility recognized residents' right to smoke and complied with local and state smoking regulations. The admission Coordinator stated he told residents the facility was non-smoking, even though the packet and policy indicated otherwise. The DON stated the facility was not providing accurate information about smoking and was not following its own policy, and that there was no documentation showing the facility was non-smoking. The facility's written policy also stated residents were informed of the smoking policy, including designated smoking areas, prior to and upon admission, and another policy stated that if the facility policy changed to prohibit smoking, residents currently allowed to smoke would be provided an area to smoke and residents admitted after the no-smoking policy was adopted would be informed on admission. The facility also failed to honor a resident's expressed preference for personal care. Resident 47 was admitted with legal blindness, thoracogenic scoliosis, a history of falling, anxiety disorder, and hypertension. Her H&P indicated she could make medical decisions, and her MDS showed intact cognition, severely impaired vision, and need for set-up or clean-up assistance with bathing, toileting hygiene, and transfers. Her care plan stated CNAs would provide care in accordance with her wishes, and a sign posted above her bed indicated she was to receive a bed bath every Sunday morning. During observation and interviews, Resident 47 stated CNA 4 did not provide the bed bath and instead brought her to the bathroom sink, gave her towels, and had her clean herself. Resident 47 stated she felt like she was going to fall and had pain when she stood up, and said she was disappointed and sad with her care. CNA 4 confirmed she did not provide the bed bath and said she was not familiar with the resident's level of assistance. CNA 5, the DSD, and the DON all stated staff should follow resident preferences and that CNA 4 should have provided the bed bath as indicated. The facility's policy stated each resident is allowed to choose options consistent with his or her interests, values, assessments, and plan of care.
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