Failure to Honor Resident's DNR Order Resulting in Unwanted CPR
Penalty
Summary
Facility staff failed to honor a resident's Do Not Resuscitate (DNR) order when the resident became unresponsive during a therapy session. Despite the resident having a clearly documented DNR status in both the electronic medical record and a DNR book at the nurses station, staff initiated Cardiopulmonary Resuscitation (CPR) after the resident slumped over and became nonresponsive. The charge nurse checked the back of the resident's door for a butterfly or heart symbol, which were used to indicate DNR or full code status, but found no indicator and proceeded with CPR. The Director of Nursing arrived with the DNR paperwork, but CPR continued until Emergency Medical Services arrived and pronounced the resident deceased. Interviews with staff revealed that DNR status was accessible in multiple locations, including the electronic medical record and a designated book, and that visual indicators were intended to be placed on resident doors. However, the absence of the visual indicator led to the initiation of CPR, contrary to the resident's documented wishes. The nurse practitioner and Director of Nursing both confirmed that staff should have followed the resident's DNR order and not performed CPR.