Failure to Honor DNR Order and Verify Code Status
Penalty
Summary
A deficiency occurred when staff failed to honor a resident's Do Not Resuscitate (DNR) order during a medical emergency. The resident, who had severe cognitive impairment and multiple medical diagnoses including dementia, diabetes, and chronic kidney disease, was found unresponsive and without a pulse. Despite the presence of a valid DNR order in both the medical record and the facility's designated binder, a registered nurse initiated chest compressions before being informed of the resident's DNR status and subsequently discontinued resuscitation efforts. Interviews revealed that the nurse involved had not received adequate training on CPR or DNR procedures, nor on how to locate a resident's code status in the electronic health record or the physical binder. Other staff members, including CNAs and LPNs, were unclear about their roles during a code situation and the process for verifying code status. The facility's policy required two nurses to verify code status before initiating CPR, but this protocol was not followed in this incident. Documentation confirmed that the resident's care plan and medical orders clearly indicated a DNR status, and the facility's policies emphasized the right of residents to refuse treatment and have their advance directives honored. However, the failure to verify and adhere to the resident's DNR order resulted in the initiation of unwanted resuscitative measures, constituting neglect as defined by the facility's own policies and federal regulations.
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 provided 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 received education on Abuse and Neglect, with emphasis on the importance of following residents' wishes regarding code status.
- Process initiated for newly hired facility staff to receive the above education during orientation and prior to working any assignment.
- Ad hoc Quality Assurance and Performance Improvement (QAPI) committee meeting conducted with the Medical Director, Administrator, Director of Nursing, and additional IDT 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.
- QAPI committee discussed ongoing monitoring audits including education validation.
- Code Blue drills continue until 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.
- Licensed nurses received additional education on 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.
- Nurses received an electronic copy of the education. Licensed nurses must complete the education prior to starting their next shift.
- Licensed nurses are required to sign the education acknowledgment sheet before working.
- Interviews conducted with CNAs working across all shifts 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.
- Licensed nurses received additional education on two nurses confirming the absence of vital signs, notifying a physician by telephone, do not text for orders, and to clearly document in the medical record.
- Licensed nurses received additional education on confirming the absence of vital signs and for residents with a DNR order nurses are required to notify the physician or Medical Director for additional orders.
- Interviews conducted with licensed nurses working across all shifts to verify training and knowledge about the new policies and processes, completed code status competencies, and participation in code blue drills.
- 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.