Failure to Honor Resident's DNR Due to Inconsistent Documentation
Penalty
Summary
The facility failed to provide care that reflected a resident's wishes as expressed in their advance directives, specifically a Do Not Resuscitate (DNR) order. Although the resident had a signed DNR order, which was also reflected in the care plan and physician's orders, the code status was inconsistently documented across various sources, including the face sheet, EMR, and the sticker on the resident's door. At the time of the incident, the face sheet and door sticker indicated the resident was a full code, while the DNR order had not yet been uploaded into the EMR due to delays in medical records processing. When the resident experienced respiratory distress and became unresponsive, staff checked the available documentation and, based on the face sheet and door sticker, initiated CPR. Emergency services were called, and CPR was continued by both facility staff and EMS, despite the existence of a signed DNR order that had not been properly communicated or documented in all necessary locations. The resident was ultimately transported to the emergency department after prolonged resuscitation efforts. Interviews with staff revealed that there were known delays in updating and scanning advance directive documents into the EMR, and that staff relied on multiple sources, such as door stickers and face sheets, to determine code status. The medical records staff acknowledged the delay in uploading the DNR order, and other staff members indicated that information about code status was not always consistent or updated in a timely manner, especially for new admissions. This lack of consistent and timely documentation led to the administration of CPR against the resident's documented wishes.