Failure to Honor DNR Order and Verify Code Status Prior to CPR
Penalty
Summary
The facility failed to honor a resident's Do Not Resuscitate (DNR) order when staff initiated cardiopulmonary resuscitation (CPR) without first verifying the resident's code status. The incident involved a resident with severe cognitive impairment and multiple comorbidities, including dementia, diabetes, vascular implants, osteoarthritis, chronic kidney disease, anxiety, depression, insomnia, hypertension, and Hodgkin's Lymphoma. The resident had a fully executed DNR order documented in both the medical record and the facility's code status binder, as well as a valid state DNR form. On the day of the incident, the resident was found unresponsive and without a pulse. A registered nurse (RN) instructed a certified nursing assistant (CNA) to call a code and began chest compressions before being informed by staff that the resident had a DNR order. The RN discontinued compressions after performing one or two chest compressions. Multiple staff interviews confirmed that the code status was not checked prior to initiating CPR, and that the expectation was for two nurses to verify code status in both the electronic health record (EHR) and the code status binder before starting resuscitative measures. Facility policy required adherence to residents' advance directives and DNR orders, with clear procedures for verifying and documenting code status upon admission and during care. Despite these policies, staff failed to follow the established process, resulting in the resident's wishes not being honored at the time of death. The deficiency was identified as Immediate Jeopardy due to the failure to respect the resident's advance directive.
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.
- Provide 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.
- Provide staff education on Abuse and Neglect, with emphasis on the importance of following residents' wishes regarding code status.
- Initiate a process for newly hired facility staff to receive the above education during orientation and prior to working any assignment.
- Conduct ad hoc Quality Assurance and Performance Improvement (QAPI) committee meetings 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 to review the plan viability of the advance directives process, code process, code status binder process, and audit results.
- QAPI committee to review education completion rates and ongoing monitoring audits including education validation.
- Continue Code Blue drills until 100% of nursing staff participate.
- QAPI committee to review ongoing audits, including validation of code status for new/re-admissions and staff education during general orientation.
- Provide licensed nurses with 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 to educate licensed nurses on evaluating residents for the absence of vital signs.
- Instruct staff 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.
- Require staff to notify the DON when a resident is noted to be absent of vital signs.
- Emphasize in education that, per the Nurse Practice Act, only a physician may pronounce death; a licensed nurse (RN or LPN) cannot do so.
- Provide 100% of the nurses with an electronic copy of the education. Require licensed nurses to sign the education acknowledgment sheet before working.
- Conduct verification of the facility's removal plan.
- Conduct interviews with CNAs 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.
- Provide licensed nurses with 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.
- Conduct interviews with licensed nurses to verify training and knowledge about the new policies and processes, completed code status competencies, and participation in code blue drills.
- Review in-service attendance signature sheets and a log of electronic communications to confirm nurse training completion.