Failure to Honor Advance Directive and Maintain Staff CPR Certification
Penalty
Summary
The facility failed to verify and follow the code status for a resident and did not ensure that licensed nursing staff maintained current CPR certification. One resident, who had a documented advance directive and physician order for Do Not Resuscitate (DNR), was found unresponsive, without a pulse or breathing. Despite the resident's clear DNR status, staff initiated CPR and continued until paramedics arrived and took over, performing multiple rounds of CPR. Staff interviews revealed that the completed POLST form indicating the resident's DNR status was not available at the time of the emergency, and staff did not verify the code status through physician orders in the electronic health record before starting resuscitation efforts. Further review showed that the facility's policies required staff to inform residents of their right to execute advance directives and to maintain copies in the medical record. The policies also stated that CPR-certified staff would be available at all times and that licensed nursing staff must maintain current CPR certification. However, two staff members, an LPN and a CNA, were found to be working without current CPR certification. One staff member admitted their certification had lapsed, and another stated they had not received recent CPR training, with their last training occurring years prior. Interviews with facility leadership confirmed that staff were expected to verify code status using the POLST form or physician orders during emergencies, but in this case, the required documentation was not accessible, and the staff did not follow the expected verification process. The lack of current CPR certification among staff and the failure to honor the resident's advance directive were directly observed and confirmed by staff and leadership during the investigation.