Failure to Honor DNR Order Due to Staff Incompetency in Code Status Verification
Penalty
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.