Failure to Honor DNR Order During Cardiac Arrest
Penalty
Summary
The facility failed to follow a physician's order for no cardiopulmonary resuscitation (DNR) for a resident who was found unresponsive, not breathing, and without a pulse. Despite the presence of a DNR order in the resident's medical record, the licensed nurse on duty initiated a Code Blue and began CPR upon discovering the resident's condition. Emergency Medical Services (EMS) were called and arrived to find CPR in progress, with the resident unresponsive and showing signs of lividity. Facility staff reported to EMS that the resident was a full code, and CPR efforts continued, including advanced interventions such as airway management, medication administration, and use of mechanical chest compression devices. The EMS team was informed of the resident's DNR status after arrival, but stated they could not stop resuscitation at that point. The resident remained in asystole throughout the resuscitation efforts, and after 25 minutes of advanced cardiovascular life support, resuscitation was discontinued. Interviews with facility staff revealed that the charge nurse did not confirm the resident's code status in the electronic medical record before initiating CPR. The nurse later acknowledged being retrained to check code status prior to starting resuscitation. The resident's family member expressed understanding and was not upset by the actions taken. The deficiency centers on the failure to adhere to the resident's DNR order at the time of the emergency.