Failure to Maintain Signed DNR Documentation Resulted in Unwanted CPR
Penalty
Summary
The facility failed to ensure that signed Do Not Resuscitate (DNR) paperwork was present in the medical record for a resident who had a physician's order for DNR-Comfort Care Arrest (DNRCCA) code status. Record review showed that although the resident had a documented DNR order, there was no corresponding signed DNR paperwork in the chart. When the resident became unresponsive and was found without a pulse, staff initiated cardiopulmonary resuscitation (CPR), including chest compressions and bagging, until EMS arrived. The nursing progress note confirmed that CPR was performed because the required DNR documentation was not available in the medical record. Staff interviews confirmed that CPR was initiated due to the absence of signed DNR paperwork, despite the presence of a physician's order for DNR status. The Director of Nursing acknowledged that the facility had not ensured the necessary DNR documentation was present to prevent resuscitation efforts. This deficiency was identified during a complaint investigation and affected one resident out of those reviewed for advance directives.