Failure to Honor DNR Order and Verify Code Status Prior to CPR
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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to provide timely CPR and EMS activation for a resident with conflicting code status documentation. A resident admitted for respite care with Hospice services was documented as Full Code in the chart, while other records referenced DNR status. When the resident was found unresponsive, staff were confused about the code status, CPR was delayed, and there was disagreement among the DON and LPNs about whether a signed DNR was present before life-saving measures were started.
A nurse performed CPR on a resident who was unresponsive and later died, but chest compressions were given while the resident remained partly on a mattress instead of on a hard surface. Surveyors also found that multiple RNs, LPNs, the DON, and the ADON had CPR certifications from an online provider without completing the required hands-on skills component, and the ED stated staff were not required to have hands-on training.
A resident with respiratory failure history and a documented full-code MOST/advance directive became unresponsive after a nebulizer treatment. An RN started CPR but stopped after a few minutes to verify code status and then reported the resident as DNR based on the wrong MOST form, so CPR was not resumed when EMS arrived.
A resident with heart failure, HTN, renal failure, DM, and COPD requested CPR and was found unresponsive with no pulse. Staff began some compressions, but the RN left to get O2, staff searched for code status, and CPR was not continued until EMS arrived. EMS reported the resident was cyanotic and started CPR on arrival, while the facility’s crash cart, Ambu bag, O2, and AED supplies were not used during the event.
A resident with multiple cardiopulmonary conditions and a documented full code status was found unresponsive without pulse or respirations during the night shift. A CNA notified the RN, who either instructed CNAs to clean and cover the resident or, per her and an LPN’s account, called a code blue and performed CPR with the LPN for about 20 minutes before stopping, without calling 911. The RN believed the resident was on hospice and did not verify code status, then notified the DON, provider, and family instead of EMS. Several hours later, after the DON called the facility and asked whether 911 had been contacted, the RN called 911 and briefly reinitiated CPR shortly before EMS arrived and pronounced the resident deceased, documenting postmortem changes. The facility’s investigation and root cause analysis found that staff failed to follow policy requiring immediate EMS activation and continuous CPR for full code residents until EMS arrival, leading to an Immediate Jeopardy finding.
An LPN and RN failed to initiate CPR when a resident was found not breathing and without a heartbeat, even though the resident's chart showed Full Code status and a care plan intervention to perform CPR. The RN relied on the LPN's assumption that the resident was DNR, and the LPN did not verify code status or call 911 before the resident was pronounced deceased.
Failure to Provide Timely CPR for a Full Code Resident
Penalty
Summary
The facility failed to contact EMS and failed to initiate and maintain CPR in a timely manner for one resident who was documented as Full Code. The resident was admitted for respite care with Hospice services in place, had a blank advance directive section on admission, and the record also contained conflicting code status documentation, including a Hospice record showing no DNR order and a care plan indicating DNR. The resident’s progress notes described a decline with fever, watery stool, draining feeding from the mouth, low blood pressure, a pulse of 35, and later unresponsiveness. On the morning of the event, staff documented that the resident was found unresponsive at 8:31 A.M. The note states that family could not be reached, the DON was informed, 911 was called, and staff started CPR on the floor until paramedics arrived and took over. The resident was pronounced dead at 9:01 A.M. The record also showed an Outside the Hospital Do-Not-Resuscitate Order signed by the physician, but staff interviews described confusion about whether the resident was Full Code or DNR at the time of the emergency. During interviews, the DON stated the resident remained Full Code unless a DNR document from Hospice was present and said life-saving measures were to be done until EMS were onsite if no DNR document existed. LPN A stated the resident’s computer profile showed DNR and that the DON told him/her to start CPR, but he/she delayed action and said there was no official copy of the DNR in the facility until after the resident had passed. LPN B stated that when he/she checked the chart, the resident was Full Code, there was no DNR form located, and CPR should have been started immediately. The Medical Director also stated staff were required to do CPR unless the signed DNR document was present and that CPR should have been started in this situation.
Improper CPR Technique and Incomplete CPR Training
Penalty
Summary
The facility failed to ensure a staff nurse performed CPR correctly for a resident who later died. The resident had diagnoses including acute on chronic diastolic heart failure, type 2 diabetes mellitus, COPD, and conversion disorder with seizures/convulsions. The resident’s MDS indicated severe cognitive impairment and independence with bed mobility, and the care plan showed the resident had an advance directive for full code status. When the resident complained of not being able to get her breath, the nurse left the room to find another nurse, then returned to find the resident unresponsive without blood pressure or an apical pulse and began CPR. Body camera footage reviewed by surveyors showed the nurse performing chest compressions while the resident remained on a pressure redistribution mattress, with the upper body on the mattress and the lower body off the side of the bed and feet on the floor. The nurse was observed standing over the resident while providing CPR, and the footage confirmed there was not a hard surface underneath the resident during compressions. The nurse later stated the resident should have been moved to a solid surface before CPR was provided, and another LPN also stated the resident had not been on a solid surface and should have been moved. The facility also failed to ensure that multiple nursing staff members who obtained CPR certification through an online provider completed the hands-on component required by the course. Surveyors reviewed CPR certifications for several RNs, LPNs, the DON, and the ADON and found the online curriculum stated hands-on training was not provided and directed users to virtual or in-person instructors for the skills component. The Executive Director stated nursing staff were not required to have hands-on training as part of the facility’s CPR certification process.
Failure to Continue CPR for a Full-Code Resident
Penalty
Summary
The facility failed to provide emergency basic life support and CPR for a resident who had a documented full code status and advance directive requesting CPR. The resident was admitted with a history of acute and chronic respiratory failure, aspiration pneumonia, dysphagia, atrial fibrillation, pulmonary hypertension, and a right arm fracture. The record showed a Colorado MOST form completed by the resident’s power of attorney indicating CPR with full treatment, a physician order identifying the resident as full code and to receive CPR, and an EMR profile screen showing an advance directive for full code/CPR. During the early morning event, an RN responded when the resident complained of shortness of breath and provided a nebulizer treatment. After the treatment, the RN documented the resident’s oxygen saturation was above 90% and that the resident was stable. About 20 to 25 minutes later, the RN returned and found the resident unresponsive, not breathing, and without a pulse. The RN instructed a CNA to call 911 and another nurse for help, retrieved oxygen, and began CPR for approximately three minutes. The RN then stopped CPR and left the room to verify the resident’s code status on the MOST form. While the RN was away, another RN and CNA arrived with the crash cart, and law enforcement arrived with an AED. The RN returned and told staff and EMS that the resident had a DNR MOST form, so CPR was not resumed. It was later discovered that the RN had referenced the wrong MOST form, and the resident’s actual code status was full code with CPR requested. The resident was pronounced deceased shortly afterward.
Failure to Provide Continuous CPR for a Full-Code Resident
Penalty
Summary
The facility failed to provide adequate CPR for a resident who had requested CPR and was found not breathing with no pulse. The resident had a BIMS score of 15 and diagnoses including heart failure, hypertension, renal failure, diabetes, and COPD. The resident had signed a CPR/DNR declaration indicating a preference for CPR and AED use to prolong life when biological death was not imminent. According to the progress notes and staff interviews, the resident complained of shortness of breath and was being cleaned up after loose stools when staff noticed her breathing slow down and then become unresponsive. Staff began some chest compressions, but the nurse left the room to obtain oxygen and later could not find all the working parts. Staff then called for help, and one CNA called 911 while another attempted CPR. Staff reported that they were unsure of the resident’s code status at first and searched for it in the facility records before finding that she was a full code. Multiple staff and EMS accounts described that CPR was not continuously performed until EMS arrived. Staff stated that compressions were stopped when the ambulance arrived, and EMS then initiated CPR. EMS reported that the resident was cyanotic and that they began CPR after entering the room. The facility had a crash cart, Ambu bag, oxygen, AED pads, and a backboard available, but staff did not use the crash cart during the event. The DON stated that CPR should begin right away for a resident who wants CPR and has no respirations or pulse, and that CPR should continue until EMS takes over.
Failure to Provide Required CPR and Activate EMS for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide immediate and appropriate basic life support, including CPR, to a resident with a documented full code status when the resident was found unresponsive. The resident had diagnoses including a slow-progressing circulatory condition involving narrowing or blockage of vessels, a condition that restricts airflow and makes breathing difficult, and other listed conditions. The physician’s order specified “Full Code,” and the care plan documented that the resident was under court-ordered guardianship with wishes honored as full code. The facility’s policy required that in the event of cardiac or respiratory arrest, staff immediately call for assistance, overhead page a code, begin CPR in the absence of a valid DNR, and continue CPR until EMS assumes responsibility or the resident responds. On the night of the incident at approximately 2:00–2:07 a.m., a CNA found the resident unresponsive in bed and notified the RN on duty. One CNA’s written statement indicated that the RN said she already knew the resident was going to die and instructed the CNA to clean and cover the resident. Another CNA’s account stated that the RN came to the room, took vital signs, and then instructed her to clean the resident. The RN’s own written statement and interview indicated that she called a code blue, that an LPN brought the crash cart, and that they performed CPR for approximately 20 minutes. The LPN’s statement corroborated that a code blue was called, that he brought the crash cart, and that CPR was performed for about 20 minutes before the RN stopped and stated that the resident was gone or words to that effect. The RN acknowledged that the resident had no vital signs but was warm and not responding, and she stated that she believed the resident was on hospice and therefore did not call 911. After CPR was discontinued, the RN did not activate EMS and instead notified the DON, the provider, and the resident’s family. The DON documented receiving a message from the RN that the resident had no pulse and no blood pressure and that the assigned nurse had initiated CPR but was unable to revive the resident. The DON later received a text from the RN that the resident had expired. The DON stated that at approximately 6:00 a.m. she called the facility and asked if 911 had been called, and upon learning it had not, she instructed the RN to call 911. The RN then reinitiated CPR at around 6:00 a.m., approximately four hours after the resident was first found without pulse or respirations, and stated that they tried to do something until EMS arrived because EMS had to see them doing CPR. EMS records showed activation at 6:18 a.m., arrival at 6:27 a.m., and pronouncement of death at 6:31 a.m., with documentation that CPR was not attempted by EMS because it was considered futile and that the resident exhibited postmortem changes. The Medical Director confirmed that the resident was full code and stated that staff should have started CPR and called 911 and that CPR should not be done four hours after a resident is pronounced dead. The facility’s investigation and a root cause analysis concluded that the RN and LPN did not follow the facility’s established policy and procedure to call 911 and administer CPR to a full code resident until EMS arrival. The root cause was identified as the nurse’s belief that the resident was on hospice and her failure to check the resident’s code status as outlined in facility policy. The surveyors determined that the failure to immediately activate EMS and to continue CPR until EMS arrival for this full code resident constituted noncompliance with the requirement to provide basic life support and resulted in an Immediate Jeopardy determination.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied. Resident #1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All codes to 1.1.26 were reviewed to ensure protocol was followed. No outliers were noted. All licensed nurses received education from the Director of Nursing and/or nursing management on [R] policy and procedure and Florida [R] policy. This includes where to find the code status. Education addressed what to do for full code hospice residents. Education completed with CNA's that protocol is that they do not assist with [R] or breaths during a [R] event. All education will be added to new hire orientation. Code drills will occur 3 x weekly x 4 weeks, followed by 2 x weekly x 4 weeks, followed by 1 x weekly x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Educated licensed nurses on CPR policy and procedure and Florida Do Not Resuscitate (DNRO) policy, including where to find code status and what to do for full code hospice residents; emphasized initiating emergency services immediately when resident is full code, continuing CPR until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS.
- Implemented emergency response “Code Blue” drills on all three shifts, including full code and full code hospice scenarios, with emphasis on calling 911 immediately.
- Educated licensed nurses and CNAs on the facility abuse and neglect policy, including resident rights.
- Required licensed nurses to complete a CPR post-test; restricted staff who have not completed education/testing from working until completion.
- Educated licensed nurses regarding change in condition.
- Placed laminated instructions on how to overhead page during a code at all nursing station phones and other designated phones.
- Held a Quality Improvement Performance Committee meeting to review root cause analysis findings and approve recommendations.
- Held a Quality Improvement Performance Committee meeting to review progress of the plan and approve recommendations.
- Completed a “like resident” audit of all expired residents and rehospitalizations for a defined period to determine whether involved staff were the same as the code event and whether proper procedure was followed.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
Basic life support, including CPR, was not initiated for a resident who was found not breathing and without a heartbeat, despite the resident having a Full Code status in the clinical record. The resident had been admitted and re-admitted after hospitalization for sepsis secondary to a urinary tract infection and had diagnoses including hypertension, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, pulmonary emphysema, anemia, COPD, and Alzheimer's disease. At the time of the event, an RN documented being called to the resident's room and finding the resident lying in bed with no heart or breath sounds, warm and clammy to the touch. The RN notified an LPN, who then contacted the family and the NP. The LPN documented that the resident had expired, and the NP documented being notified that the patient was pronounced deceased. The record also showed the resident's code status as Full Code, with a care plan intervention to perform CPR and notify the physician of any change. During interviews, the RN stated she relied on the LPN's word that the resident was DNR and pronounced the resident without knowing the resident was Full Code. The LPN stated she checked for a pulse and heartbeat, told aides to get the RN because she could not pronounce death, did not check the code status, and did not start CPR. A CNA stated that when the resident was found not breathing, the nurse was notified, the LPN checked the resident, and no 911 call or CPR attempt was made.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.