Failure to Honor DNR Order for Resident
Penalty
Summary
The facility failed to follow physician orders regarding a resident's code status. The resident, who had diagnoses including combined systolic and diastolic heart failure, pericardial effusion, pleural effusion, and thrombocytopenia, was admitted with a documented Do Not Resuscitate (DNR) order as indicated on both the Pennsylvania Orders for Life Sustaining Treatment (POLST) form and a physician order in the electronic clinical record. Despite these clear directives, when the resident was found unresponsive with slow, shallow breathing and low oxygen saturation, nursing staff initiated a Code Blue, called 911, and performed CPR, including administering multiple rounds of epinephrine. The nursing progress note detailed that the resident was given oxygen and that CPR was started by staff until paramedics arrived, contrary to the DNR order. The Director of Nursing confirmed during an interview that the facility did not implement the physician's DNR order for this resident. This failure to honor the resident's documented code status constituted a deficiency in following physician orders and respecting the resident's end-of-life preferences.