Failure to Honor DNR Order Due to Misinterpretation of POLST
Penalty
Summary
The facility failed to honor a resident's Physician Orders for Life-Sustaining Treatment (POLST) indicating Do Not Resuscitate (DNR), Do Not Intubate, and Allow Natural Death. After the resident, who had Alzheimer's disease and had been a DNR since admission, became unresponsive following a fall, an LPN initiated cardiopulmonary resuscitation (CPR) despite the DNR order. The LPN misread the POLST document, as her finger covered the DNR check mark, leading her to interpret the code status as full code and begin CPR. The ambulance staff continued lifesaving efforts and transported the resident to the hospital, where further resuscitation was attempted. Interviews with facility staff revealed inconsistent practices for verifying code status, with some staff relying on the POLST in the chart, others on the electronic medical record, and some on chart spine color coding. The LPN involved stated she had received training on reading POLST forms but still misinterpreted the document in the emergency. The resident's family member, who was the appointed healthcare representative, confirmed the resident's DNR status and expressed concern upon learning that CPR had been performed. The facility's policy required verification of code status before initiating CPR, but this protocol was not followed in this incident.
Removal Plan
- Health unit coordinator, nurse manager, and registered nurses check all resident charts to ensure POLST matches the electronic medical record banner and the chart's spine color.
- Staff are educated on emergency protocols.
- Staff are educated on where to check code status.
- Two people verify the POLST.
- Audits are completed with staff and training is verified.
- Code drills are completed where staff read the POLST and correctly identify if a full code or DNR.
- Ongoing audit schedule evaluates staff knowledge regarding the POLST and where to find the code status.