Failure to Honor Resident's DNR Due to Incomplete Medical Record Update
Penalty
Summary
Facility staff failed to honor a resident's Do Not Resuscitate (DNR) advanced directive when they performed Cardiopulmonary Resuscitation (CPR) and notified Emergency Medical Services (EMS) to complete all life-saving measures. This occurred because the DNR order, although signed by the resident and uploaded to the miscellaneous section of the medical record, was not accurately entered into the physician orders or reflected in the resident's medical record banner. As a result, staff were unable to quickly verify the resident's code status during the emergency. The resident involved was on hospice services, had a diagnosis of lung cancer and depression, and was dependent on staff for all activities of daily living. The resident had intact cognitive skills and had signed a DNR order prior to the incident. However, the admission record did not list an advance directive, and the electronic medical record did not indicate the DNR status. When the resident was found unresponsive, staff checked the available records and, not finding the DNR status, initiated CPR and called EMS, who continued resuscitation efforts until the resident was pronounced deceased. Interviews with staff revealed that the process for updating code status was not consistently followed. Social services had uploaded the DNR and notified nursing to change the code status, but the nurse responsible was interrupted and did not complete the entry. The code status was not updated in the physician orders or on the code status roster, leading to confusion during the emergency. Staff relied on the code status report and the medical record banner, both of which did not reflect the resident's DNR status, resulting in the failure to honor the resident's documented wishes.