Failure to Honor Advance Directive Resulting in Unwanted CPR
Penalty
Summary
The facility failed to follow the advance directive for one resident who had a documented Do Not Attempt Resuscitation (DNAR) order. The resident, who had multiple serious diagnoses including end stage renal disease, heart failure, and cancer, was found unresponsive with no pulse or respiration. Despite the presence of a completed POLST form indicating no CPR, staff initiated cardiopulmonary resuscitation (CPR) before confirming the resident's code status. The nurse directed a CNA to call 911 and began CPR while checking the resident's DNR status, and the CNA also performed compressions until being told to stop when the DNR was confirmed. The CNA involved stated she was unaware of the need to verify code status before starting CPR and expressed concern about the lack of a clear system to identify residents' code status. Documentation in the medical record and the CPR checklist confirmed that CPR was performed on the resident in contradiction to her advance directive. The facility's policy required staff to review and communicate advance directives, but this was not followed in this instance, resulting in the resident receiving unwanted resuscitative efforts.