Failure to Honor Resident DNR Status During CPR
Penalty
Summary
Staff failed to follow a resident's documented Do Not Resuscitate (DNR) code status when the resident was found unresponsive with no pulse or respirations. Despite the presence of an advance directive and an active physician's order indicating DNR/DNI status, staff initiated and continued cardiopulmonary resuscitation (CPR) for approximately 20 minutes before the Director of Nursing (DON) arrived and instructed them to stop after verifying the resident's code status. The nurses involved reported that they began CPR, checked the code status, but continued resuscitation efforts under the belief that once CPR was started, it should not be stopped until emergency medical services arrived. The resident's code status was documented in both the electronic medical record (EMR) and on hall sheets that staff were expected to carry. Interviews revealed that while some staff understood the need to verify code status before initiating CPR, others did not follow this protocol during the incident. Additionally, a certified nursing assistant (CNA) reported that orientation training did not specifically address code status procedures, and the DON was unable to provide signed documentation verifying which staff attended a post-incident educational meeting on advance directives and code statuses. Facility policies required staff to provide basic life support, including CPR, unless a valid DNR order was in place, and indicated that code status information was accessible in the EMR and hall sheets. However, there was no evidence of ongoing auditing or monitoring to ensure staff awareness and adherence to these protocols at the time of the incident. The failure to verify and honor the resident's DNR status before and during resuscitation efforts constituted the deficiency.