Failure to Honor Advance Directive for Full Code Resident
Penalty
Summary
Facility nursing administration failed to provide effective oversight to ensure that nursing staff assessed and implemented the correct Advance Directive for one of eleven sampled residents reviewed for Advance Directives. The resident, who had diagnoses including cerebral atherosclerosis, dysphagia, gastro-esophageal reflux disease, anemia, constipation, hypertension, and hyperlipidemia, was admitted to hospice services but maintained a Full Code status as specified in both the physician's order and the updated POLST form. The resident's responsible party also confirmed the desire for Full Code status. Despite these clear directives, when the resident was found without a pulse or respirations, there was no evidence that CPR was attempted by facility staff. Interviews with the DON revealed that nursing staff mistakenly believed that hospice admission automatically meant Do Not Resuscitate (DNR) status, leading to the failure to initiate CPR. The incident occurred during a shift change, with both day and night shift nurses present in the facility. The DON confirmed that the staff were already notifying hospice when she arrived at the resident's room and that she was later informed by staff that the resident was a Full Code. Documentation and staff interviews confirmed that the resident's wishes for resuscitation were not honored at the time of death.