Failure to Honor Resident's DNRCC-A Advance Directive
Penalty
Summary
Staff failed to honor a resident's documented code status regarding advance directives. The resident had a signed Do Not Resuscitate Comfort Care - Arrest (DNR CC-A) order, which specified that all interventions should cease at the point of cardiac or respiratory arrest, and no CPR should be performed. Despite this, when the resident was found cyanotic with a respiratory rate of three breaths per minute, staff initiated CPR, including chest compressions and respirations, before confirming the absence of a pulse and respirations. Interviews revealed that both the LPN and RN involved did not understand the meaning of the DNRCC-A order and proceeded with resuscitation efforts. The DON confirmed that staff were confused about the code status and that CPR should not have been initiated for a resident with a DNRCC-A order. The error was only recognized after emergency medical technicians arrived and confirmed the resident's DNR status.