Failure to Honor Resident's DNR Order Resulting in Unwanted CPR
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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Advance Directive Not Maintained in Resident Record: A resident with dementia, muscle weakness, and protein-calorie malnutrition had documentation indicating an advance directive was in the chart, but record review did not locate a living will or DPOA for health care. The CNO confirmed the record did not include an advance directive and the facility did not have a living will on file.
Incomplete Advance Directive Documentation: The facility failed to keep complete and accurate advance directive records for two residents. One resident's chart contained a representative-signed acknowledgement that did not specify the type of advance directive, and another resident's record had no signed acknowledgement showing that advance directives were discussed. The SSD stated she was responsible for the documentation and that one form was filled out incorrectly while the other resident's paperwork could not be found.
The facility failed to timely respond to changes in condition for two residents, including one with severe cognitive impairment and another with dementia, CHF, diabetes, and a history of UTIs. Family members and DPOAs reported concerns about confusion, agitation, pain, SOB, and other worsening symptoms, but hospital evaluation was delayed while staff waited for physician input. Both residents were later admitted to the hospital with serious infections and other acute conditions, including sepsis, pneumonia, and respiratory failure.
A facility failed to ensure that active physician orders matched residents’ POLST code status for three residents. One resident with COPD, A-Fib, and anxiety had a POLST indicating DNR but no active code status order; another resident with dementia, hypothyroidism, and HTN had a POLST indicating DNR but a physician order for CPR; and a third resident with COPD, respiratory failure, and diabetes had a POLST indicating DNR but no active code status order. The DON confirmed the records were inconsistent and that physician orders and POLST should match.
A resident with dementia with agitation, stroke, and PE had an advanced directive noted in a care conference review, but the document could not be found in the medical record. Staff later confirmed the resident did not have an advance directive on file.
Failure to offer a resident the opportunity to create an advance directive. Record review showed the resident had no advance directive on file, and the SS Director stated there was no documentation that education was provided or that any attempts were made to obtain one. The resident had HTN, CKD, and mild cognitive impairment.
Advance Directive Not Maintained in Resident Record
Penalty
Summary
The facility failed to ensure that a copy of a resident's advance directive was maintained in the medical record for Resident #32, who was admitted with multiple diagnoses including dementia, muscle weakness, and protein-calorie malnutrition. The resident's care plan, revised 5/12/22, documented that the resident and appointed healthcare representative were to receive education regarding advance directives as needed, and a care conference evaluation dated 6/26/26 documented that the resident had an advance directive in the record. However, on 7/8/26, review of the medical record did not locate a living will or durable power of attorney for health care, and the CNO later confirmed that the record did not include an advance directive and the facility did not have a living will on file.
Incomplete Advance Directive Documentation
Penalty
Summary
The facility failed to ensure documentation regarding advance directives was complete and accurate for 2 of 7 residents reviewed. A policy titled "Advance Directives and Refusal of Treatment" stated that upon admission the Social Services Designee should obtain a copy of any existing Living Will, Health Care Proxy, Durable Power of Attorney for Health Care Decisions, or other recorded declaration and enter a progress note regarding the existence of an advance directive. Resident #7 was admitted with diagnoses including hemiplegia and hemiparesis following a nontraumatic intracerebral hemorrhage affecting the right dominant side. The record contained a "Resident Rights & Advance Directive Acknowledgement" signed by the resident's representative that indicated the resident had an advance directive, but the form did not identify the type of advance directive. Resident #81 was admitted with end stage renal disease, and the medical record contained no signed acknowledgement showing that advance directives were discussed with the resident or representative. The Social Services Director stated she was responsible for advance directive documentation, that the form for Resident #7 was filled out incorrectly and should have been corrected, and that the missing paperwork for Resident #81 meant the facility would not know whether the resident had an advance directive.
Delayed Response to Changes in Condition and Family Requests for Hospital Evaluation
Penalty
Summary
The facility failed to timely provide requested medical evaluation and treatment for two residents with changes in condition. The deficiency was identified during review of Complaint #3035494 and involved delayed responses to worsening symptoms, resulting in delayed medical treatment, worsening of condition, and dissatisfaction with care. For one resident with diagnoses including Alzheimer's disease and other medically complex conditions, the record showed severely impaired cognition and inability to make decisions. A family member reported that the resident had a decline in health about a week before hospitalization, with severe UTI and stool impaction. The hospital record documented that the resident arrived from the nursing home via EMS with confusion and altered mental status that had worsened since several days earlier, and the ED physician suspected sepsis. The resident was febrile, tachycardic, had elevated white blood cell count and creatinine, and was diagnosed with proctitis, cystitis, sepsis, NSTEMI, and acute kidney injury. The urine culture was positive for gram-negative rods/Pseudomonas aeruginosa. For another resident with diagnoses including diabetes mellitus, a history of UTIs, CHF, Alzheimer's disease, and dementia, the progress notes showed family concerns about abnormal behavior, confusion, agitation, shortness of breath, congestion, lethargy, and shallow breathing. The resident's DPOA reported repeatedly expressing concern that something was wrong and requesting hospital evaluation, but the facility did not immediately send the resident out and instead contacted the physician first. The change-in-condition documentation noted altered mental status and respiratory symptoms, and the physician initially recommended a nebulizer treatment before later directing transfer to the ED. The resident was admitted to the hospital with bilateral pneumonia, acute hypoxic respiratory failure, likely demand ischemia, chronic diastolic CHF, fluid overload, severe anemia, and human metapneumovirus infection.
Physician Orders Did Not Match POLST Code Status
Penalty
Summary
The facility failed to ensure that active physician orders reflected residents’ end-of-life wishes as documented on their Pennsylvania POLST forms for three residents. Facility policy stated that residents are presumed to consent to CPR unless there is documentation in the medical record showing a DNR order, and that all DNR orders must be rewritten by the attending physician for each admission or readmission. Review of the clinical records showed that Resident R14 had diagnoses including COPD, A-Fib, and anxiety, and had a POLST indicating DNR, but the current physician orders lacked evidence of code status. Resident R38 had diagnoses including dementia, hypothyroidism, and high blood pressure, and had a POLST indicating DNR; however, a physician order dated in the record indicated CPR, creating inconsistency between the POLST and the physician orders. Resident R50 had diagnoses including COPD, respiratory failure, and diabetes, and had a POLST indicating DNR, but current physician orders also lacked evidence of code status. During interviews, the DON confirmed that Resident R14’s record lacked active physician orders reflecting code status and that Resident R38’s physician orders and POLST were not consistent, and further confirmed that resident physician orders and POLST should match regardless of the POLST.
Advance Directive Not Available in Resident Record
Penalty
Summary
The facility failed to ensure a resident exercised the right to formulate an Advance Directive. Review of the State Operations Manual, record review, and staff interview showed that Resident #5 had an advanced directive documented on a Care Conference Review Comprehensive dated 4/3/26, but the document could not be located in the medical record. Resident #5 was admitted and later readmitted to the facility with diagnoses including dementia with agitation, stroke, and pulmonary embolism. On 6/26/26 at 9:48 AM, a request was made for a copy of Resident #5's advanced directive. Later that day at 11:19 AM, the CEO confirmed that Resident #5 did not have an advanced directive on file. The report states that this deficiency involved 1 of 5 residents whose records were reviewed.
Failure to Offer Advance Directive Opportunity
Penalty
Summary
The facility failed to ensure residents were offered the opportunity to create an advance directive for Resident #13, who was re-admitted with multiple diagnoses including hypertension, chronic kidney disease, and mild cognitive impairment. Record review on 6/24/26 showed that Resident #13 did not have an advance directive on file. On 6/25/26 at 2:43 PM, the Social Service Director stated there was no documentation that education was provided to Resident #13 and no attempts were made to obtain an advance directive.
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