Failure to Withhold CPR for Resident with DNR Order
Penalty
Summary
Facility staff failed to withhold cardiopulmonary resuscitation (CPR) for a resident who had a documented do not resuscitate (DNR) order. The resident was found unresponsive by a restorative nursing aide, and the Director of Nursing (DON) initiated the facility's code blue process. CPR was started based on verbal confirmation from a certified nursing assistant (CNA) and a registered nurse (RN) that the resident was a full code, without first verifying the resident's code status in the advance directives binder or electronic medical record. The DNR order was only discovered after CPR had already been initiated and emergency medical services (EMS) had arrived. Interviews revealed that staff were trained to check the advance directives binder and the resident's electronic medical record to confirm code status before starting CPR, as per facility policy. However, in this incident, the CNA and RN provided incorrect verbal information regarding the resident's code status, and the DON relied on this information rather than verifying the DNR order. The facility's policy required confirmation of code status prior to initiating CPR, but this step was not followed, resulting in CPR being performed on a resident with a valid DNR order.