Failure to Honor Resident's DNR Order Resulting in Unwanted CPR
Penalty
Summary
The facility failed to honor a resident's Do Not Resuscitate (DNR) order, resulting in the initiation of Cardiopulmonary Resuscitation (CPR) against the resident's documented wishes. On the date of the incident, a registered nurse (RN) found the resident unresponsive and without a pulse. The RN instructed a certified nursing assistant (CNA) to call a code and began chest compressions. After performing two compressions, the RN was informed that the resident had a DNR order in place and discontinued CPR. The DNR order was present in the resident's medical record and in the code status binder at the nurses' station, and the resident's care plan clearly indicated the existence of a DNR order. The resident involved had significant medical conditions, including dementia with severe cognitive impairment, Type 2 Diabetes Mellitus, vascular implants, osteoarthritis, chronic kidney disease, anxiety, depression, insomnia, hypertension, and Hodgkin's Lymphoma. The resident's DNR order was fully executed and documented in both the electronic health record and the physical code status binder. Despite these clear directives, staff failed to verify the resident's code status before initiating CPR, which was contrary to the resident's end-of-life wishes and facility policy. Interviews with staff revealed gaps in training and knowledge regarding code status verification and DNR procedures. The RN involved reported that orientation did not include education on Code Blue or DNR procedures, nor was she trained on how to locate a resident's code status in the electronic health record. Other staff members confirmed that the code status was not checked prior to the initiation of CPR. Facility policy required verification of code status by two nurses before starting CPR, but this protocol was not followed, resulting in the resident's DNR wishes not being honored.
Removal Plan
- Audit of the code status binders to validate DNR forms are in the appropriate binder.
- Audit to verify residents' DNR forms are present in the electronic medical record, physician orders are in place, and care plans are reflective of residents' code status.
- Staff education instructing licensed nurses to evaluate residents for absence of vital signs, and if vital signs are absent, to follow residents' Advanced Directive. If the resident has DNR orders, notify the provider for further orders.
- Staff education on Abuse and Neglect, with emphasis on the importance of following residents' wishes regarding code status.
- Education completed by all staff, excluding those on leave from work.
- Process initiated for newly hired facility staff to receive the above education during orientation and prior to working any assignment.
- Quality Assurance and Performance Improvement (QAPI) committee meeting conducted with the Medical Director, Administrator, Director of Nursing, and Interdisciplinary team members to review adherence to policy and procedure for advance directives, code status in the electronic health record, code status binders, following physician orders, and results of the root cause analysis.
- QAPI committee reviewed the plan viability of the advance directives process, code process, code status binder process, and audit results.
- QAPI committee reviewed education completion rates for licensed nurses and all other staff; staff on leave will be educated upon return.
- QAPI committee discussed ongoing monitoring audits including education validation; all staff interviewed answered questions appropriately.
- Code Blue drills continue until all nursing staff participate.
- QAPI committee reviewed ongoing audits, including validation of code status for new/re-admissions and staff education during general orientation.
- QAPI committee continued review of ongoing monitoring audits including education validation, code status validation for new/re-admissions, and orientation education.
- Completed audits titled 'Code staff education validation' observed; no issues identified.
- Licensed nurses received additional education regarding two nurses confirming the absence of vital signs and notifying the health care provider by telephone, not text, for orders and to clearly document in the medical record.
- Director of Nursing and Unit Manager designees began educating licensed nurses on evaluating residents for the absence of vital signs. Staff instructed that if vital signs are absent, they must follow the residents' Advanced Directive. For residents with DNR orders or if death occurs in the facility, the physician must be notified for further orders. Staff are also required to notify the DON when a resident is noted to be absent of vital signs. Education emphasized that, per the Nurse Practice Act, only a physician may pronounce death; a licensed nurse (RN or LPN) cannot do so.
- All nurses received an electronic copy of the education. Licensed nurses are required to sign the education acknowledgment sheet before working.
- Verification of the facility's removal plan conducted by the survey team through interviews with CNAs and licensed nurses to verify education related to their role during a Code Blue, the Stop, Think, and Perform process, resident rights, participation in Code Blue drills, and education on resident rights.
- In-service attendance signature sheets and a log of electronic communications reviewed, which confirmed that nurses received the in-service training about the new processes.