Failure to Obtain Valid DNR Results in Unwanted CPR
Penalty
Summary
The facility failed to respect a resident's right to refuse or discontinue treatment by not obtaining a valid, physician-signed Do Not Resuscitate (DNR) order for an elderly female resident with severe cognitive impairment and multiple medical conditions. Although the resident's care plan and admission documents indicated a DNR status, the actual Out-of-hospital DNR form in the resident's file was unsigned by a physician, rendering it invalid. As a result, when the resident was found unresponsive, staff initiated CPR under the assumption that she was a full code, as there was no valid DNR on file. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for verifying and maintaining accurate code status documentation. The Director of Nursing (DON), Assistant Director of Nursing (ADON), charge nurses, social worker, and other staff provided inconsistent accounts of who was responsible for ensuring the presence of a valid DNR order upon admission. Some staff believed the admitting nurse or social worker was responsible, while others cited the DON or admission coordinator. The facility's policy required a physician-signed DNR to be present in the resident's medical record, but this was not adhered to in this case. The absence of a valid DNR led to the resident receiving CPR against her and her family's wishes, causing emotional distress to the family. The incident was further complicated by the fact that the previous facility failed to forward the completed DNR documentation during the resident's transfer. Staff interviews highlighted the negative impact of not having clear code status documentation, including the risk of violating resident rights and providing unwanted medical interventions.