Failure to Honor Advance Directives and Timely Initiate CPR
Penalty
Summary
The facility failed to ensure that a resident's advance directives were implemented in a timely manner and did not honor the resident's wishes regarding full code status. A resident with multiple serious diagnoses, including metabolic encephalopathy, multiple sclerosis, sepsis, dysphagia, acute respiratory failure with hypoxia, diabetes type 2, pneumonia, acute kidney failure, myocardial infarct, and hypertension, was documented as cognitively intact and had an active order for full code status. Despite this, when the resident's oxygen saturation dropped to 84% with supplemental oxygen, the LPN on duty did not notify the medical provider or document any interventions regarding this significant change in condition. Later, the resident was found pulseless and not breathing. There was confusion among staff regarding the resident's code status, as conflicting information was found between the hospital transfer form, which indicated DNR, and the facility's electronic health record, which indicated full code. Staff delayed initiating CPR for approximately 45-60 minutes while attempting to clarify the resident's code status, contacting administration, hospice, and the medical team instead of following the full code order present in the record. During this time, no resuscitative efforts were made, and the resident was ultimately pronounced dead. Interviews with staff revealed a lack of clarity and understanding regarding the process for verifying and acting on code status, as well as inconsistent documentation and communication. The facility's policy required that any changes to advance directives be properly documented and communicated, but this was not followed. The failure to promptly initiate CPR in accordance with the resident's documented wishes and physician orders resulted in the resident's wishes not being honored.
Removal Plan
- An audit of each resident's code status was completed.
- The licensed nurse was suspended, pending the facility's investigation.
- A Quality Improvement Performance Committee was conducted to review the recommendations from the root cause analysis.
- A performance improvement plan was developed and initiated based on root cause analysis as determined by the QAPI committee.
- Code blue drills were initiated on multiple shifts, with ongoing drills to continue until all staff have completed and with the results reported to the QAPI committee.
- The regional director of social services provided education to licensed nurses and the interdisciplinary team on advanced directives including identification of a valid DNR and who can initiate a DNR, with a posttest upon completion.
- Licensed nurses and CNAs received education on the CPR policy and procedure including responding to a code blue and the roles/responsibilities during a code.
- Staff received education related to the abuse, neglect, exploitation, and misappropriation policy.
- Licensed nurses received education on the identification of a change in condition including competency.
- Newly hired licensed nurses will receive education upon hire, or accepting a shift, to include the CPR policy/procedure, advanced directives policy/procedure, identification of change in condition with competency, abuse/neglect/exploitation/misappropriation, and participation in code blue drills.
- Ongoing training is being conducted for the identification of change in condition with competency.