Failure to Honor Resident DNR Status During Emergency Response
Penalty
Summary
The facility failed to ensure that personnel honored a resident's advance directive regarding resuscitation. A resident with an Out-of-Hospital Do Not Resuscitate (OOH-DNR) order and a documented DNR status in the medical record was found unresponsive. Despite the clear DNR status, a nurse initiated CPR and performed two chest compressions, causing the resident to moan in pain. The nurse admitted to not being aware of the resident's DNR status at the time and did not check the code status binder on the crash cart before starting CPR. The nurse only became aware of the DNR after a subsequent phone call with the physician and upon later review of the binder. Multiple staff interviews confirmed that the code status binder, which contains up-to-date information on all residents' resuscitation preferences, was available and located on the crash cart. However, the nurse involved did not consult this resource before acting. Other staff members, including CNAs, stated they attempted to communicate the resident's DNR status to the nurse during the event, but the nurse did not hear or respond to this information. The facility's policy required staff to check the code status before initiating CPR, but this protocol was not followed in this instance. The resident involved had a history of multiple rib fractures, dementia, Parkinson's disease, and cognitive impairment, and was admitted for rehabilitation. Documentation showed the resident's DNR status was consistently recorded in the admission record, care plan, and physician orders. The incident was not immediately reported to the state agency, and there was a lack of documentation and training regarding code status protocols among staff at the time of the event.