Failure to Honor Resident DNR Order Resulting in Unwanted CPR
Penalty
Summary
A deficiency occurred when staff failed to honor a resident's advance directive regarding code status. Specifically, a nurse performed CPR on a resident who had a documented Do Not Resuscitate (DNR) order, as indicated by a Physician Order for Life Sustaining Treatment form. The facility's policy stated that CPR should not be initiated if a provider's medical order indicates DNR status, yet this was not followed in the case of this resident. The incident was documented in the resident's nursing notes, which described the resident being found unresponsive and CPR being performed despite the DNR order. The resident was subsequently sent to the hospital for further evaluation and later returned to the facility. An administrative staff member confirmed during an interview that the nurse performed CPR against the resident's code status and acknowledged that staff are expected to follow such orders.