Failure to Honor Advance Directive Due to Miscommunication of DNR Status
Penalty
Summary
The facility failed to follow and/or clarify a physician's order regarding advance directives for one resident. According to the facility's policy, residents' wishes concerning life-sustaining treatment, such as Do Not Resuscitate (DNR) and Do Not Intubate (DNI) orders, are to be clearly documented and honored, typically through a POLST form. In this case, the resident had a POLST form signed by their power of attorney, indicating a DNR status. However, when the resident was found unresponsive, staff initiated resuscitation efforts, including chest compressions and oxygen administration, before the nurse supervisor questioned the resident's code status and it was confirmed that the resident was DNR. This incident was confirmed through review of the clinical record, facility policy, and staff interviews. The miscommunication regarding the resident's code status led to actions that were not in accordance with the documented advance directive. The deficiency was identified for one of eight residents reviewed, and the facility's failure to honor the resident's documented wishes was substantiated by the evidence collected during the survey.