F0600

J

Failure to Honor DNR Resulting in CPR Performed Against Resident’s Wishes

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) status and right to refuse CPR, resulting in CPR being performed against the resident’s documented wishes. The resident had multiple serious medical diagnoses, including myasthenia gravis, immunodeficiency, COPD, acute pulmonary edema, peripheral vascular disease, prior TIA, cerebral infarction without residual deficits, and adult failure to thrive. The medical record contained multiple physician orders documenting DNR status, including a State of Florida yellow DNR form signed by the resident and physician and scanned into the electronic health record. The resident’s care plan documented that the resident had capacity to make health care decisions and had signed a DNR, and advance care planning notes and a hospitalist progress note also confirmed DNR status and the resident’s preference for comfort-focused care.

On the day of the event, the resident complained of shortness of breath and was noted to be hypoxic, with oxygen saturation documented as low as 55%. Nursing staff contacted the provider, who ordered transfer to the ER. While the assigned LPN left the room to prepare transfer paperwork, another RN responded to the room after being told assistance was needed. That RN brought the crash cart, suctioned the resident for drooling, and observed agonal breathing followed by cessation of breathing. Multiple witnesses reported that this RN directed the response in the room, instructing staff to obtain oxygen equipment and suction, to place the resident on the floor with a backboard, and to initiate chest compressions. Several LPNs took turns performing chest compressions, and paramedics were called and took over CPR when they arrived. Staff reported that a code blue was not called overhead and that the resident’s code status was not verified before CPR was started.

Interviews and record review showed that staff performing and directing CPR either did not check the resident’s code status or assumed someone else had done so. The assigned LPN stated he did not realize the resident was a DNR because the face sheet showed full code, and another LPN stated she began compressions based on the RN’s direction without confirming code status. The RN leading the response did not verify the code status prior to initiating compressions, and staff reported that the resident’s DNR status was only recognized after CPR had been in progress and EMS was already on scene. A timeline from the facility’s investigation documented that chest compressions began at 3:18 p.m., EMS arrived at 3:23 p.m., the DNR status was identified at 3:35 p.m., and DNR documentation was provided to EMS at 3:38 p.m., at which time compressions were discontinued. In total, chest compressions were performed for approximately 20 minutes on a resident who had an active DNR order and documented wishes not to be resuscitated. The surveyors determined that this failure resulted in a situation that created a worsened condition and the likelihood for serious injury and/or death and constituted Immediate Jeopardy.

The report also notes that the facility’s policies required staff to identify and follow each resident’s advance directives, including referring to the yellow DNR form and physician orders before initiating CPR. Staff interviews revealed inconsistent understanding and use of tools to verify code status, such as a code status book or code blue sheets, and multiple staff stated they had not seen or used code blue logs or worksheets prior to this event. The Nursing Home Administrator acknowledged that the expectation was for staff to assess a resident and determine code status before initiating CPR, and that if a resident had DNR orders, chest compressions should not be performed. Despite these policies and expectations, the resident’s clearly documented DNR status was not checked or followed before CPR was initiated and continued for an extended period.

Removal Plan

• Disciplinary action/suspension was initiated for two nurses
• RN was terminated and reported to Board of Nursing
• Nurse files were reviewed and it confirmed CPR certification, license, skills checklists and backgrounds were present for 100% of nurses
• Ad hoc QAPI meetings were held to discuss concern and correction plan
• Ad hoc meeting was held to review IJ citations
• Ad hoc meeting was held to provide additional education to evaluate and reinforce education previously provided on code status, abuse, neglect, and exploitation (ANE); reviewed and approved a code blue worksheet; reviewed and approved an abuse posttest to reinforce prior education
• Ad hoc meeting was held to review, revise and approve code blue worksheet
• Revised code blue worksheet was taken to units and staff review of the worksheet was initiated
• Implemented that anyone can complete the code blue worksheet
• Educated 100% of nurses on advance directives, resident right to make a decision, emergency care (CPR), and ANE
• New licensed staff were educated on abuse and code status upon hire