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
Resources
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Failure to Promote Resident Self-Determination: A resident with CVA, DM2, and difficulty walking had blue mats left on the floor while out of bed, blocking access to the refrigerator. The resident stated he could not reach his pop and yogurt, while an NA, an LPN, and the ADON all stated the mats should be moved out of the way when the resident was not in bed and that he was able to self-propel to the refrigerator.
A cognitively intact resident with a spinal fracture and dependence for bathing was scheduled for showers twice weekly, but she reported receiving only bed baths since admission despite wanting showers. Staff gave conflicting accounts about shower access and assistance, and one NA stated he did not provide a shower because it was too much work and required extra help, while the DON and Administrator stated the resident should have received a shower if she wanted one.
Failure to Honor Bathing Preferences: Two residents did not receive the showers they preferred and were scheduled for, and instead were given bed baths without documentation of shower refusal. One resident with fx of the L femur, DM, and muscle weakness stated he had not received a shower since admission, while another resident with dementia, anxiety, muscle weakness, and depression had only received bed baths despite a stated preference for showers. Staff and the DON confirmed showers were to be offered first and refusals documented, but no refusal documentation was found.
A resident with alcohol dependence, severe cognitive impairment, and repeated intoxication was frequently loud, cursing, argumentative, and disruptive during overnight hours, waking other residents who said they wanted to sleep through the night. EHR entries and staff interviews showed he often returned late at night intoxicated, refused redirection, played loud music, and yelled at the nurses’ station, while staff reported they could not get him to stop and often left him be if he was not hurting himself or others.
Failure to honor a resident’s bathing preference. A resident with acute and chronic respiratory failure, chronic diastolic failure, cerebral infarction, and weakness had a documented preference for showers and required substantial to maximal assistance with bathing. Despite this, the shower log showed bed baths were provided instead of showers on multiple occasions, and the RDON confirmed the resident had not received the preferred showers.
A resident with intact cognition and total ADL dependence was not assisted out of bed for 3 consecutive days despite requesting his usual morning routine. NA staff and a nurse confirmed the resident remained in bed because of staffing call outs and a lack of 2 staff needed for a mechanical lift transfer, and the resident said he was frustrated at being stuck in bed.
Failure to Promote Resident Self-Determination
Penalty
Summary
The facility failed to promote independence for one resident with cerebral infarction affecting the left side, type 2 diabetes, and difficulty walking. The resident’s care plan identified a fall risk and directed that blue mats be placed on each side of the bed when in bed to provide a safe environment with even floors free from clutter. During observation, the resident was sitting in a wheelchair while blue mattress mats were left on the floor on the opposite side of the bed and were blocking access to the refrigerator. The resident stated he was not able to access his pop or yogurt in the refrigerator. A nursing assistant stated the resident needed help with ADLs and keeping the room organized, and that staff were expected to move the mats when the resident was out of bed. An LPN stated the resident was able to self-propel enough to retrieve items from the refrigerator and that the mats should not be left on the floor when the resident was out of bed. The ADON stated mats were expected to be removed from the floor and placed out of the way when residents were not in bed, and that it was an issue if a resident could not access the refrigerator when capable of doing so.
Resident Denied Requested Shower
Penalty
Summary
The facility failed to honor a resident’s choice to receive a shower instead of a bed bath. Resident #28 was admitted with a wedge compression fracture of the T10-T19 vertebrae and the admission MDS indicated she was cognitively intact and required substantial to maximal assistance for bathing and showers. Her care plan directed staff to provide substantial to maximal assistance with showers, transfer her with a mechanical lift, encourage participation in self-care, and report refusals of ADL care, personal hygiene, bathing, or showers to the nurse. Her record also showed she was scheduled for showers on Tuesdays and Thursdays. During interview, Resident #28 stated she wanted a shower but had only received bed baths since admission and said the shower stretcher was broken and unsafe. Staff interviews showed conflicting information about shower access and use: one nurse stated residents needing a shower stretcher would go to the 200 Hall shower room, where the stretcher was observed in working condition, while a nurse aide stated he had given the resident bed baths or washed her in her wheelchair and had not given her a shower because it was a lot of work and required another staff person. The unit manager stated the resident had only one shower since admission and should have been receiving showers if she wanted them. The DON and Administrator both stated they would expect the resident to receive a shower if she wanted one.
Failure to Honor Residents’ Bathing Preferences
Penalty
Summary
The facility failed to honor the bathing preferences of two residents by providing bed baths instead of the showers they preferred and were scheduled to receive. Resident #73, admitted with diagnoses including fracture of the left femur, diabetes, and muscle weakness, had a care plan for ADL assistance and a Kardex indicating showers on Tuesday and Friday evenings, but the care plan did not reflect the resident’s bathing preference. Review of facility documentation from 6/16/2026 through 7/1/2026 showed no showers were given, and the record contained no documentation that Resident #73 refused showers. During interviews, Resident #73 stated he had not received a shower since admission and had only received bed baths, although his preference was a shower. Resident #106, admitted with diagnoses including dementia, anxiety, muscle weakness, and depression, had a care plan for ADL assistance but no bathing preference documented. The resident’s Kardex indicated showers on Wednesday and Saturday, yet documentation from 5/27/2026 through 6/27/2026 showed only bed baths were provided, including on multiple listed dates, with no showers given per the resident’s preference. The Responsible Party stated Resident #106 had not had a shower in over 30 days and preferred showers. Staff interviews confirmed showers were to be offered first, refusals were to be documented and reported to the nurse, and bed baths were only to be offered if a shower was refused; however, no documentation of shower refusal was found for either resident, and the DON confirmed both residents received bed baths instead of their preferred showers.
Resident’s Nighttime Intoxication and Disruptive Behavior Woke Other Residents
Penalty
Summary
The facility failed to ensure that residents could choose their sleeping and waking schedules according to their preferences when one resident’s repeated intoxication, loud yelling, cursing, and argumentative behavior during the night repeatedly woke other residents. The cited residents included four cognitively intact residents who stated they were awakened multiple times overnight and preferred to sleep through the night without being disturbed. The facility census was 71 residents. Resident #8 had diagnoses including alcohol dependence, tobacco dependence, alcohol abuse, and COPD with supplemental oxygen dependence. His MDS showed severe cognitive impairment with a BIMS score of 7 out of 15 and noted verbal behaviors, other behaviors not directed toward others, and rejection of care. His care plan addressed mood disturbance, alcohol use, refusal of care, restlessness, irritability, sleep problems, yelling behavior toward staff, and included interventions such as encouraging rest, using relaxation techniques, speaking calmly, documenting behaviors, and maintaining respect for resident rights to make his own lifestyle choice. The EHR documented multiple episodes in which Resident #8 was intoxicated, loud, belligerent, and disruptive to other residents, including yelling at the nurses’ station, cursing at staff and co-residents, refusing redirection, playing loud music, returning with alcohol late at night, and waking other residents. Staff interviews confirmed that he frequently left the facility late in the evening, returned intoxicated in the middle of the night, and woke other residents when he came back. Staff also stated that when attempts were made to redirect him, he became more argumentative and louder, and that the decision was often to leave him be if he was not hurting himself or others. The facility policy stated residents have the right to considerate and respectful care and reasonable accommodation of individual needs except where the health, safety, or rights of the resident or other individuals would be endangered.
Failure to Honor Resident Bathing Preferences
Penalty
Summary
The facility failed to honor Resident #77’s bathing preferences by providing bed baths instead of showers. Resident #77 was admitted with diagnoses including acute and chronic respiratory failure, chronic diastolic failure, cerebral infarction, and weakness, and the MDS indicated no memory issues and substantial to maximal assistance needed for bathing and showering. The resident’s documented preference dated 6/03/26 was for showers, and the care plan identified risk for decline in ADLs related to a fall at home. Despite this preference, the shower log showed the resident received bed baths on 06/11/26, 06/15/26, and 06/18/26. During interview, Resident #77 stated he was receiving bed baths and preferred showers, and the RDON confirmed the resident had received bed baths rather than showers on those dates and that the resident’s preferences would be honored.
Failure to Honor Resident Choice for Getting Out of Bed
Penalty
Summary
The facility failed to honor a resident’s right to self-determination and choice when Resident #100 was not assisted out of bed for 3 consecutive days. Resident #100 was admitted with diagnoses of diabetes and neuropathy, had intact cognition per the quarterly MDS, and was dependent for all activities of daily living, including transfers. His care plan documented that he required assistance with all ADLs and transfer by mechanical lift with 2 staff. The resident stated he asked NA #3 to get him up each morning and was told there was no staff available, and he reported feeling frustrated because he was stuck in bed and wanted to be up by breakfast time. NA #3 confirmed she was assigned to the resident’s hall on the affected days and stated there were NA call outs with no replacements. She said nursing staff decided residents would remain in bed so staff could provide care, explaining there was not enough time to get residents up and back to bed for care. NA #3 confirmed the resident requested to get up each of the 3 days but could not be accommodated because there were not 2 staff available for the mechanical lift transfer. Nurse #6 stated staff were informed that residents were kept in bed due to staffing, and the DON and Administrator stated they were not aware that residents remained in bed for staff to provide care.
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