Failure to Honor DNR/DNI Orders Due to Staff Error
Penalty
Summary
The facility failed to honor a resident's Do Not Resuscitate (DNR) and Do Not Intubate (DNI) orders. The resident, who had multiple diagnoses including chronic kidney disease and diabetes, was found unresponsive by CNA staff. Nursing staff assessed the resident and determined the code status was DNR. However, an LPN entered the room with a Physician Orders for Scope of Treatment (POST) document, incorrectly identifying the resident as a full code, and initiated CPR. The POST document was later found to belong to a different resident. CPR was stopped only after the ambulance crew arrived and the correct DNR status was confirmed. The resident's physician order, POST, and care plan all documented DNR status, and staff interviews confirmed that CPR should not have been started.