Failure to Honor Resident DNR/DNI Status During Emergency Response
Penalty
Summary
Nursing staff failed to honor a resident's right to self-determination regarding advanced directives when they initiated CPR on a resident who had a documented Do Not Resuscitate (DNR) and Do Not Intubate (DNI) order. The resident, who had diagnoses including schizoaffective disorder, diabetes mellitus, dysphagia, and GERD, had clear documentation in the medical record, hospital discharge summaries, and a signed MOLST form indicating DNR/DNI status. The resident's code status had also been discussed with the health care agent and was reflected in the physician's orders. On the day of the incident, the resident experienced a choking event and, after the Heimlich maneuver was performed, became unresponsive and was found without a pulse. Nursing staff, uncertain of the resident's code status, checked the electronic medical record and incorrectly determined the resident was a full code. As a result, a code blue was called and CPR was initiated by two nurses until EMS arrived. It was only after EMS took over that the correct MOLST form was located, confirming the resident's DNR/DNI status, and CPR was stopped. Interviews with staff revealed that the advanced directives and MOLST form were not properly identified or communicated at the time of the emergency. The Director of Social Services acknowledged missing the advanced directives upon admission, and the Director of Nursing stated that staff are expected to physically verify the MOLST form during emergencies. The failure to accurately verify and honor the resident's advanced directives led to the initiation of unwanted resuscitative efforts.