Failure to Honor Resident DNR Status Results in Unwanted CPR
Penalty
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.