Failure to Honor Resident's DNR Advance Directive
Penalty
Summary
The facility failed to honor a resident's advance directive regarding Do Not Resuscitate (DNR) status. The resident, who had diagnoses including muscle weakness, atrial fibrillation, cognitive communication disorder, heart failure, and peripheral vascular disease, was documented in the electronic medical record (EMR) and care plan as having a DNR order, signed by both the resident and her medical provider. Despite this, when the resident was found unresponsive, staff initiated cardiopulmonary resuscitation (CPR) without verifying her code status in the EMR. The nursing report sheet incorrectly indicated she was a full code, leading staff to begin CPR. Interviews with facility staff revealed that the expectation was for staff to check the care plan or physician's orders for updated advanced directives before initiating emergency interventions. However, in this incident, staff did not verify the resident's DNR status prior to starting CPR. The facility was unable to provide a policy related to advance directives when requested by surveyors. This failure to follow the resident's documented wishes and established procedures resulted in the deficiency.