Failure to Honor DNR Order Due to Staff Incompetency in Code Status Verification
Summary
Nursing staff failed to verify and honor a resident's Do Not Resuscitate (DNR) order when the resident was found unresponsive and without a pulse. Despite the presence of a valid DNR order in the medical record and code status binders, a registered nurse initiated chest compressions before being informed of the resident's DNR status, at which point resuscitation efforts were discontinued. The incident occurred after the nurse instructed a CNA to call a code and began CPR, only stopping after being notified of the DNR order. The resident involved had multiple diagnoses, including dementia, Type 2 Diabetes Mellitus, vascular implants, osteoarthritis, chronic kidney disease, anxiety, depression, insomnia, hypertension, and Hodgkin's Lymphoma. The resident's care plan and medical record clearly indicated a DNR order, and the resident was severely cognitively impaired, as evidenced by a low BIMS score. Staff interviews revealed that the nurse involved had not received specific training on CPR or DNR procedures, nor on how to locate code status information in the facility's systems or binders during orientation. Further review of facility policies, job descriptions, and orientation materials showed that while procedures and competencies regarding code status and DNR orders existed, they were not effectively communicated or implemented with all staff. The nurse involved was unaware of the location of DNR documentation and the process for verifying code status, leading to the failure to honor the resident's advance directive at the time of the emergency. This deficiency resulted in the determination of Immediate Jeopardy.
Removal Plan
- Audit 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 to follow residents' Advanced Directive if vital signs are absent.
- If the resident has DNR orders, staff are to 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 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 ongoing monitoring audits including education validation; ensure staff interviewed answer questions appropriately.
- Continue Code Blue drills until all nursing staff participate.
- QAPI committee to review ongoing audits, including validation of code status for new/re-admissions and staff education during general orientation.
- QAPI committee to continue review of ongoing monitoring audits including education validation, code status validation for new/re-admissions, and orientation education.
- Provide licensed nurses 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 and following the residents' Advanced Directive.
- For residents with DNR orders or if death occurs in the facility, notify the physician 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.
- Distribute an electronic copy of the education to all nurses.
- Require licensed nurses to sign the education acknowledgment sheet before working.
- Conduct 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.
- Review in-service attendance signature sheets and a log of electronic communications to confirm training completion.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
LPNs Assigned Wound Care Without Competency Assessment: Several LPNs were assigned wound care duties for residents even though the facility had not assessed their competencies or provided wound care training. The LPNs stated they had limited or no wound care education or certifications, and some said they did not feel comfortable performing wound care. Leadership confirmed wound care responsibilities had been shifted to floor nurses and that no competency evaluations or training had been provided.
Licensed nursing staff did not have competencies completed on hire, and the facility did not ensure staff had the skills needed to carry out resident care and monitor changes in condition. One resident’s positive urine culture was not reported to the NP for days, and another resident did not receive ordered BID BG checks; abnormal lab results and a recommendation for IV fluids were documented, but no follow-up was found in the record. The facility assessment listed competency areas such as change in condition and BG testing, and the Regional RN confirmed new-hire competencies were not being completed.
Lack of Mechanical Lift Competency for Direct Care Staff: A resident sustained a witnessed fall from a Hoyer lift during a transfer by two staff members and was later noted to have pain in the RUE and bilateral hips, with a head strike also documented. Review of staff files showed one LNA had no documented mechanical lift training or competency, and a Support Aide who sometimes helped with Hoyer transfers reported she had not received facility training on transfers or lift use.
An LVN failed to follow a resident's oxycodone order by administering the medication when documented pain scores were below the ordered parameter. The LVN could not explain medication parameters or what to do when a resident was outside the parameter, and the DON stated that medication parameters are used for resident safety and that not following them can cause complications, medication toxicity, and ineffective treatment.
Missing Staff Orientation, Competency, and Performance Documentation: The facility failed to ensure required orientation, annual competency skill assessments, and annual performance evaluations were completed for multiple staff members. Record review found an LPN with an expired CPR card, an RN with no CPR card or orientation checklist after rehire, and several CNAs with missing skills checklists, orientation forms, or annual performance reviews; HR staff said records were not kept up and were not filed properly.
Failure to In-Service CNA on Merry Walker Safety for High-Fall-Risk Resident: A resident with severely impaired cognition, dementia, multiple prior falls, and a care plan for a helmet, Merry walker, and 1:1 sitter fell while ambulating with the device after abruptly standing and losing balance. CNA 1 stated she had not received in-service training or a report on the resident's risks or the safe use of the walker, and the resident sustained a nasal fracture and forehead laceration requiring transfer to a GACH.
LPNs Assigned Wound Care Without Competency Assessment
Penalty
Summary
Nursing staff were assigned to provide wound care to residents without having their competencies assessed or receiving wound care training. During interviews, S10LPN stated he was providing wound care to assigned residents, but the facility had not assessed his competencies or provided training before assigning him wound care responsibilities. S8LPN stated she was a recent graduate with limited clinical experience, had no certifications or educational background in wound care management, did not feel comfortable providing wound care without proper education and training, and had not been assessed or trained before being assigned wound care duties. S7LPN and S9LPN also stated they were providing wound care to assigned residents despite having no certifications or educational background in wound care management, and both said the facility had not assessed their competencies or provided training before assigning them wound care tasks. S9LPN stated she did not feel comfortable providing wound care because of her lack of education and training in wound management procedures and protocols. S5IPSDC confirmed wound care responsibilities had recently been assigned to floor nurses after the wound care nurse position was eliminated, and S2IDON confirmed nursing staff were not provided education or training in wound care management and that the facility had no competency assessments or evaluations for S7LPN, S8LPN, S9LPN, and S10LPN to provide wound care.
Nursing Competency and Communication Failures
Penalty
Summary
Licensed nursing staff did not complete competencies on hire and did not demonstrate the skill sets needed to care for residents based on assessed needs. The facility assessment listed training and competencies for the nursing department, including monthly education, orientation and training for new hires, and competency skill sets such as identifying resident change in condition and diabetic blood glucose testing. Review of employee files showed RN #507 and LPN #518 did not have nursing competencies completed on hire, and the Regional RN confirmed the facility had not been ensuring all licensed nursing staff had nursing competencies on hire. For one resident with diagnoses including atherosclerotic heart disease, gastroenteritis and colitis, muscle weakness, a stage 3 sacral pressure ulcer, peptic ulcer, malnutrition, bradycardia, hypotension, and intestinal bypass status, a urine culture positive for infection was reported to the facility but was not communicated to the NP until 13 days later. The resident was later hospitalized and treated for bradycardia, unresponsiveness, and IV antibiotics for a UTI caused by ESBL Klebsiella pneumoniae and E. coli. For another resident with hemiplegia and hemiparesis following cerebral infarction, CHF, hypothyroidism, and a history of GI bleed, an order required blood glucose checks twice daily, but the MAR showed only one check on one day. A dietary technician documented abnormal BUN, creatinine, and GFR results and recommended review for IV fluids and change in condition, but progress notes showed no follow-up on that recommendation, and both an LPN and NP stated they were not aware of the IV fluid recommendation.
Lack of Mechanical Lift Competency for Direct Care Staff
Penalty
Summary
The facility failed to ensure that direct care staff had the specific competencies and skill sets necessary to meet residents’ needs related to the use of a mechanical lift. A fall investigation showed that a resident sustained a witnessed fall from a mechanical lift during a transfer from a chair to a bed by two staff members. A provider progress note documented that the resident was being evaluated after the fall from a Hoyer lift and reported pain in the right upper extremity and bilateral hips, with a head strike also noted. The facility assessment, last updated 11/11/25, identified that residents required services including transfer assistance with a mechanical Hoyer lift and stated that staff would be trained and evaluated for competencies related to lift assistance. Review of four LNA training files showed that one LNA lacked documented training or competency for operating a mechanical Hoyer lift. An interview with a Support Aide revealed that she occasionally assisted LNAs with Hoyer lift transfers but had not received facility training on how to transfer or assist in transferring a resident. The facility Educator stated that the Support Aide’s role did not include transferring residents or assisting with transfers, especially with a mechanical lift, and confirmed that all direct care staff were required to complete specific training and annual competency assessment to operate a mechanical lift; she also confirmed that the LNA had no evidence of completing the mechanical lift competencies.
Nursing Staff Failed to Follow Oxycodone Medication Parameters
Penalty
Summary
LVN 1 failed to follow Resident 1's physician order for oxycodone 5 mg by mouth every three hours as needed for severe pain. Resident 1 was admitted with cervical spinal stenosis and diabetes mellitus, and the H&P dated 5/12/2026 described the resident as alert and oriented x4. The MDS dated 5/14/2026 indicated the resident's cognitive skills for daily decision making were intact and that the resident was independent with all activities of daily living. The MAR showed oxycodone was administered on 5/11/2026, 5/12/2026, 5/13/2026, and 5/23/2026 even though the recorded pain scores were 4, 4, 2, and 4, respectively. During interview and observation, LVN 1 stated a medication parameter was used for medication ranges and guidance on when to give certain medications, but was unable to explain the medication administration process when a medication had parameters or what to do if a resident was not within the parameter. LVN 1 stated the pain scale for oxycodone was 5-10, yet also stated oxycodone was given because the resident and family requested it and that giving it for pain scores of 2 and 4 was following doctor orders. The DON stated medication parameters were used for resident safety and that not following them could cause complications, medication toxicity, and the medication would not help for the medication purpose and resident's diagnosis. The facility's competency policy stated nursing staff competency includes areas such as communication, medication management, and pain management.
Missing Staff Orientation, Competency, and Performance Documentation
Penalty
Summary
The facility failed to ensure that orientation, annual competency skill assessments, and annual performance evaluations were completed for 3 of 3 licensed staff and 5 of 5 unlicensed staff reviewed. During record review and interview, Human Resource staff K stated she had only been at the facility for 1 month and that records were not kept up, were moved around, and were not filed in alphabetical order. The facility’s policy stated that competency evaluation is required for all care team members, that initial competency is evaluated during orientation, and that ongoing and annual competency evaluations occur based on training program evaluation, job performance evaluations, identified performance gaps, or regulatory requirements. Record review showed missing or incomplete documentation for multiple staff members. An LPN had an expired CPR card, another LPN had a skills validation checklist but no annual performance records, and an RN had no CPR card and no orientation skills checklist from the rehire date. Among CNAs, one had no skills checklist or orientation form, one had a skills assessment checklist but no annual performance review, one had a background check for the assisted living side of the building that was not rechecked for LTC/skilled care and no 2026 skills checklist or annual performance review, one had no orientation skills checklist, and one had a skills validation checklist but none for 2026 and no annual performance review. When asked whether any additional documents were available, staff K stated she would have to ask the DON, and the surveyor would only accept documents until the end of the survey exit conference.
Failure to In-Service CNA on Merry Walker Safety for High-Fall-Risk Resident
Penalty
Summary
The facility failed to ensure CNA 1 was in-serviced and given clear instruction on the protocols for mitigating physical and environmental hazards, including falls, for a resident who had a history of falls and was using a Merry walker for ambulation. Resident 1 had diagnoses including encephalopathy, protein calorie malnutrition, dementia, muscle weakness, disorder of bone density and structure, a prior fracture of the fifth metacarpal of the left hand, Alzheimer's disease, anxiety disorder, depression, hypertension, and adult failure to thrive. The resident's MDS dated 5/15/2026 indicated severely impaired cognition and need for varying levels of assistance with activities of daily living, including supervision for upper body dressing, partial moderate assistance with toileting hygiene, showering, bathing, and personal hygiene, substantial/maximal assistance with lower body dressing, and dependence for putting on and taking off footwear. The resident's record showed 12 separate falls in the facility, and the care plan identified unavoidable fall risk related to gait and balance problems, dementia, and non-compliance using a walker, with interventions including a helmet during ambulation, a Merri walker for ambulation, and a 1:1 sitter. On 6/12/2026, CNA 1 was assigned to monitor and supervise the resident while ambulating with the Merry walker. CNA 1 stated the resident stopped to rest, sat on the walker seat for about 2 minutes, then abruptly stood, held the front of the walker, and started walking; the resident lost balance and fell face forward. CNA 1 stated she had worked at the facility for 1 month and had not received in-services on the risks and hazards associated with a resident using a Merry walker, and she was not provided a report explaining why the resident was using the device or what behaviors and risks to watch for. The resident sustained a nasal fracture and a laceration to the forehead and was transferred to a GACH for further evaluation and management.
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