Failure to Honor Resident's DNR Order Resulting in Unwanted Resuscitation
Penalty
Summary
A deficiency occurred when facility staff failed to honor a resident's documented Do Not Resuscitate (DNR) order, resulting in the resident receiving life-saving interventions against his expressed wishes. The resident, who was cognitively intact and had clearly indicated his preference for DNR status on a signed POLST form, experienced a change in condition. Multiple staff members, including CNAs and nurses, observed and reported the resident's declining status, but there was confusion and lack of clarity regarding his code status at the time of the emergency. Despite the resident's POLST form being uploaded to the electronic medical record, staff reported difficulty accessing or reading the code status during the critical event. As the resident became unresponsive, staff initiated CPR, used mechanical ventilation, and applied an AED, all of which were specifically prohibited by the resident's advance directive. Several staff members admitted they were unaware of the resident's DNR status and proceeded with resuscitation efforts based on assumptions or instructions from other staff, rather than verifying the resident's documented wishes. After the event, it was confirmed through interviews and record review that the resident's DNR status was known to some staff but not effectively communicated or accessible to those providing care during the emergency. The failure to follow the resident's advance directive led to the resident being transferred to the hospital, where he ultimately expired after further resuscitative measures were performed. The deficiency was identified as Immediate Jeopardy due to the facility's failure to ensure that the resident's right to refuse life-sustaining treatment was honored.