Failure to Honor Do Not Resuscitate Order During Code Event
Penalty
Summary
The facility failed to ensure that a resident's Do Not Resuscitate (DNR) advance directive was followed. The resident, who had a signed Medical Order for Life Sustaining Treatment indicating DNR status, was found unresponsive and without vital signs. Despite the presence of a yellow wristband indicating DNR and documentation in the electronic medical record, nursing staff initiated cardiopulmonary resuscitation (CPR) efforts. The initial responding nurse did not check the resident's wristband or properly verify the code status in the electronic medical record, and incorrectly informed the supervising nurse that the resident was a full code. As a result, CPR was started and continued until staff became aware of the resident's DNR status. Multiple staff members, including the Registered Nurse Supervisor and a Certified Nursing Assistant, participated in resuscitation efforts. The Registered Nurse Supervisor also failed to verify the resident's code status before continuing CPR and only discovered the DNR order after checking the electronic medical record during the event. Emergency Medical Services were called and continued involvement until they were informed of the DNR order, at which point resuscitation efforts ceased. Interviews with staff revealed that the initial nurse was unfamiliar with code procedures and did not follow facility protocol for verifying advance directives. The resident involved had a history of hypertension, diabetes mellitus, and atherosclerotic heart disease, and was documented as having moderately impaired cognition. The facility's policy required staff to check for a DNR wristband and verify advance directives in the electronic medical record before initiating resuscitation. However, these procedures were not followed, resulting in the administration of unwanted life-sustaining treatment contrary to the resident's documented wishes.