F0578

J

Failure to Honor DNR Order During Code Event

South Pasadena, Florida Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to honor a resident’s Do Not Resuscitate (DNR) order and advance directive during a cardiopulmonary arrest. The resident had multiple significant diagnoses, including myasthenia gravis, immunodeficiency, COPD, acute pulmonary edema, peripheral vascular disease, history of TIA and cerebral infarction, and adult failure to thrive. The medical record contained physician orders documenting DNR status on multiple occasions, and the care plan stated the resident had capacity to make health care decisions and had signed a DNR, with the signed Florida DNR form scanned into the electronic health record. A hospitalist progress note also documented that the resident was DNR and had declined invasive measures such as a PEG tube, opting for comfort-focused care and liberalized diet for quality of life.

On the day of the incident, the resident complained of shortness of breath and was noted to be hypoxic, with oxygen saturation documented as low as 55%. The assigned LPN assessed the resident, contacted the NP, and obtained orders to transfer the resident to the ER. While the assigned LPN left the room to prepare transfer paperwork, another RN (the nurse manager) was notified and went to the resident’s room with the crash cart. According to interviews and the facility’s internal timeline, the RN found the resident in respiratory distress, drooling, and directed staff to obtain towels, oxygen equipment, suction, and a non-rebreather mask. The resident was suctioned, placed on a non-rebreather, and then lowered to the floor. The RN did not verify the resident’s code status before directing staff to initiate chest compressions.

Multiple nurses, including several LPNs, participated in performing chest compressions, rotating as directed by the RN who was leading the code. Staff reported that a code blue was not called overhead and that they assumed someone had checked the resident’s code status. The assigned LPN later stated he did not realize the resident was a DNR because this was not indicated on the face sheet. Another LPN discovered the resident’s DNR status while preparing transfer paperwork and questioned why CPR was being performed. EMS arrived and instructed staff to continue compressions until they could review documentation; compressions continued until the yellow Florida DNR form was produced and provided to paramedics. The facility’s investigation and timeline showed that chest compressions were performed for approximately 20 minutes before being discontinued, despite the presence of a physician-signed DNR order and a scanned Florida DNR form in the record, resulting in the facility’s failure to follow the resident’s advance directive and physician orders.

The facility’s own policies on Emergency Care (CPR) and Advance Directives required staff to identify and honor each resident’s choice for treatment, to use the yellow DNR form as the physician order concerning CPR, and to refer to the presence of the yellow form and/or physician orders to determine if CPR should be performed in a cardiac emergency. Interviews with the Nursing Home Administrator and regional clinical leadership confirmed that, prior to this event, the process relied on the nurse to verify code status in the electronic health record and dashboard, and that in this incident the resident’s code status was not verified before CPR was initiated. The surveyors determined that this failure to honor the resident’s DNR and advance directive caused unnecessary physical harm and pain and denied the resident a peaceful death, and that it created a situation resulting in a worsened condition and likelihood for serious injury and/or death, leading to an Immediate Jeopardy determination.

Removal Plan

• Initiated disciplinary action and suspension for two nurses.
• Terminated an RN and reported the RN to the Board of Nursing.
• Reviewed nurse files to confirm CPR certification, licensure, skills checklists, and background checks were present for all nurses.
• Held ad hoc QAPI meetings to discuss the concern and correction plan.
• Held an ad hoc meeting to provide additional education and reinforce prior education on code status and abuse, neglect, and exploitation (ANE), and to review and approve a code blue worksheet and an abuse posttest.
• Held an ad hoc meeting to review, revise, and approve the code blue worksheet.
• Implemented staff review of the revised code blue worksheet on the units and allowed any staff member to complete the code blue worksheet.
• Educated all nurses on advance directives, resident right to make decisions, emergency care (CPR), and ANE.
• Educated new licensed staff on abuse and code status upon hire.
• Reviewed all resident medical records to verify code status orders.
• Audited residents who expired in the facility to confirm code status was honored.
• Initiated and continued mock code drills on varying shifts and days.
• Reviewed and verified code status for all new admissions.
• Provided reinforcement education to nurses to verify and document code status orders.
• Implemented the code drill worksheet and revised it to include a checkbox for full code/DNR.
• Provided additional education to non-licensed staff to reinforce prior education on code status, who can perform CPR and emergency care, advance directives, ANE, and their role during a code blue.
• Continued reinforcement education and required staff to complete it prior to working their next shift.