Failure to Honor DNR Order During Emergency Response
Penalty
Summary
A deficiency occurred when facility staff failed to honor a resident's Do Not Resuscitate (DNR) advanced directive. The resident, who had Alzheimer's disease and was receiving hospice services, had a clearly documented DNR status in the clinical record, care plan, and physician orders. Despite this, after the resident experienced an unwitnessed fall resulting in a head laceration and seizure activity, a Licensed Practical Nurse (LPN) initiated chest compressions on the resident. The LPN, upon finding the resident on the floor with seizure activity and snoring respirations, checked the code status and then called 911. While on the phone with the dispatcher, the LPN was instructed to begin CPR and performed light chest compressions, even though the resident had a heartbeat and was still breathing. The resident subsequently came out of the seizure, and her breathing returned to normal before EMS arrived and transported her to the hospital for evaluation. Interviews with facility staff and the resident's representative confirmed that the advanced directive was known and accessible in the resident's chart. The resident's representative expressed distress that CPR was initiated despite the DNR order. The facility's policy stated that care should reflect the resident's wishes as expressed in the advanced directive, but this was not followed during the incident.