Failure to Honor DNR Order During CPR Event
Summary
Facility staff failed to honor a resident’s physician-ordered Do Not Resuscitate (DNR) status when the resident was found unresponsive and staff initiated Cardiopulmonary Resuscitation (CPR), including chest compressions, without first confirming code status. The resident had a documented history of serious medical conditions 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 DNR form signed by the resident and physician and scanned into the electronic health record, as well as care plan entries and advance care planning notes confirming the resident’s wish to be DNR and to avoid aggressive interventions such as feeding tubes. 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 nurse left the room to prepare transfer paperwork, another RN responded to the resident’s respiratory distress, brought the crash cart, and began directing the emergency response. Staff reported that the resident was drooling, appeared to be in respiratory distress, and was suctioned and placed on a non-rebreather mask. During this process, the resident developed agonal breathing and then stopped breathing. At the direction of the RN leading the event, the resident was lowered to the floor and chest compressions were initiated by an LPN, with subsequent rotation of multiple nurses performing compressions. Multiple staff involved in the code, including LPNs and RNs, acknowledged that the resident’s code status was not verified before CPR was started. Staff assumed the resident was a full code, and one LPN stated she did not check code status because she was specifically called by the RN to start compressions. Another LPN later discovered in the electronic record that the resident was DNR while CPR was ongoing. Paramedics arrived and instructed staff to continue compressions until they could review documentation; CPR continued for approximately 20 minutes until the yellow State of Florida DNR form was produced, at which point EMS stopped compressions and the resident expired. The surveyors determined that by providing CPR, staff failed to honor the resident’s advance directive and signed DNR order, causing unnecessary physical harm and pain and denying the resident a peaceful death, and this failure resulted in a determination of Immediate Jeopardy. Interviews with the Nursing Home Administrator and regional clinical leadership confirmed that the facility’s policy required staff to determine a resident’s code status, including reference to the yellow DNR form and physician orders, before initiating CPR. The NHA stated that if a resident had DNR orders, the expectation was that staff would not perform chest compressions and would instead focus on comfort. The facility’s policies on emergency care (CPR), advance directives, and resident rights all emphasized honoring the resident’s treatment choices and using the signed yellow DNR form as the physician order concerning CPR. Despite these policies and the presence of clear DNR documentation in the record and care plan, staff did not verify code status prior to initiating CPR, leading to the Immediate Jeopardy finding.
Removal Plan
- Disciplinary action/suspension was initiated for two nurses.
- The RN involved was terminated and reported to the Board of Nursing.
- Nurse files were reviewed and confirmed CPR certification, license, skills checklists, and background checks were present for 100% of nurses.
- Ad hoc QAPI meetings were held to discuss the concern and correction plan.
- An ad hoc meeting was held to review IJ citations and to plan additional education on code status and abuse/neglect/exploitation (ANE), approve a code blue worksheet, and approve an abuse posttest to reinforce prior education.
- An ad hoc meeting was held to review, revise, and approve the code blue worksheet.
- The revised code blue worksheet was taken to units and staff review of the worksheet was initiated.
- Education was provided to 100% of nurses on advance directives, resident right to make decisions, emergency care (CPR), and ANE.
- New licensed staff were educated on abuse and code status upon hire.
- A 100% review of resident medical records was completed to verify code status orders.
- An audit of residents who expired in the facility in the past 90 days was conducted with no concerns found related to honoring code status.
- Mock code drills were initiated and continued on varying shifts and days.
- Code status for all new admissions was reviewed and verified.
- All nurses received reinforcement education to verify and document code status orders.
- Implementation of the code drill worksheet began and feedback was incorporated to add a checkbox for full code/DNR.
- Additional education was provided 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.
- Reinforcement education was ongoing and staff were to complete it prior to working their next shift.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with intact cognition, multiple medical diagnoses, and documented full code status was found unresponsive, pulseless, and nonbreathing while receiving care. An RN believed Hospice enrollment changed the code status to DNR and did not start CPR or call a code blue, despite the resident’s full code order being documented in the chart.
A resident with respiratory failure and COPD, whose advance directives and orders indicated Full Code, was found unresponsive by an RN. The RN checked for a pulse, confirmed the resident was gone, but did not start CPR or call EMS; another nurse also assessed the resident, and the resident was pronounced dead shortly after. Family members and the DON stated CPR was not initiated despite the resident’s Full Code status.
A resident with a documented DNRCCA order had CPR started during a respiratory emergency before the code status was verified, despite staff records showing the resident was DNRCCA and cognitively impaired. Staff reports described confusion during the event, with CPR initiated while family members were present and code status confirmation occurring after compressions had already begun. In a separate record review, another resident’s chart showed DNRCCA in the EMR and care plan, but the hard chart lacked signed code status documentation.
Ambu Bag Not Readily Available During Code Blue: A Full Code resident was found unresponsive and not breathing, and staff began CPR during a Code Blue, but an ambu bag was not readily available at the start of the event. Staff used a non-rebreather mask while looking for the ambu bag, and interviews confirmed the device was not in use when the code began. The DON stated an ambu bag is part of the expected emergency equipment and that a non-rebreather mask does not replace it.
A resident with full code status became unresponsive and staff began chest compressions, but an LPN did not immediately call 911 and CPR was performed without ventilations or rescue breathing. EMS arrived to find staff doing compressions only and documented that the resident had been without ventilations for more than 12 minutes before EMS initiated BVM ventilations and continued resuscitation efforts.
RN 2 did not maintain CPR/BLS certification from a provider that included the required hands-on skills component. File review showed the certification came from an online provider, and RN 2 stated the course was entirely online with reading, videos, and questions only, with no CPR skills demonstration. The DSD confirmed the certification needed hands-on validation under the facility CPR policy.
Failure to Provide CPR for Full Code Resident
Penalty
Summary
Facility staff failed to provide basic life support, including CPR, for a resident who was found pulseless and nonbreathing. The resident had diagnoses including peritoneal abscess, type 2 diabetes, and severe protein-calorie malnutrition, and a quarterly MDS assessment indicated a BIMS score of 13 out of 15, showing intact cognition. The resident was their own decision maker and had a documented full code status signed and dated in the medical record. The resident was enrolled in Hospice services, and on the night of the incident, CNA-G and CNA-H were providing a bed bath while RN-E entered the room to complete a skin check and change a dressing on the resident’s buttocks. After the dressing change, the resident began having loose stools. RN-E left to get additional wound supplies while the CNAs continued care, and CNA-H thought the resident had passed away and left to notify RN-E. RN-E returned, found the resident unresponsive without observable respirations or signs of life, and believed the code status had changed to DNR when Hospice services began. RN-E did not initiate CPR or call a code blue, and instead asked LPN-F to inform Hospice of the resident’s passing. The investigation found that the resident’s code status was accurately documented in the medical record, physician orders, and care plan, and that RN-E was aware the resident was full code but failed to follow the resident’s documented wishes and the facility’s emergency response procedures.
Failure to Initiate CPR and Call EMS for Full Code Resident
Penalty
Summary
The facility failed to initiate CPR and call EMS for a resident who was found unresponsive and had Full Code status. The resident had been admitted from an acute care hospital and had diagnoses including acute and chronic respiratory failure with hypoxia and hypercapnia, as well as COPD. Advance directives, the order summary, and the MAR/TAR all identified the resident as Full Code, and a progress note documented that the resident wanted to remain Full Code. According to the record and staff interviews, the resident was last seen at about 4:45 AM when a breathing treatment was started. At about 5:50 AM, an RN entered the room to tell the resident the shift was ending, found no response, touched the resident, and checked for a radial pulse, which was absent. The RN then went to the hallway and alerted the incoming nurse that the resident was gone. The RN later checked the chart and confirmed Full Code status, but CPR was not started and EMS was not called. Another nurse was present and also assessed the resident, with absent apical pulse confirmed, and the resident was pronounced dead at 6:00 AM. Family members stated they were told the RN panicked and did not start CPR or call EMS. The DON confirmed that the resident was Full Code and that the RN who found the resident unresponsive did not initiate CPR or check code status right away. The facility policy stated that when a resident is found without heartbeat and respirations, the nurse on duty identifies code status and, if the resident is Full Code, CPR is started and 911 is activated.
Advance directives not honored during CPR event and code status documentation incomplete
Penalty
Summary
The facility failed to honor advance directives for a resident with a documented DNRCCA order when CPR was initiated during a respiratory emergency. Resident #91 was admitted with acute respiratory failure with hypoxia, pulmonary embolism, and tracheostomy status, and the record showed the resident was cognitively impaired, totally dependent for ADLs, and had a physician order and care plan identifying DNRCCA status. During the event, staff were alerted that the resident was having trouble breathing, and the respiratory therapist entered the room, found the resident not breathing, and began CPR before the code status was verified. According to the facility investigation and staff statements, multiple staff members responded to the room, the crash cart was brought in, and CPR continued while EMS was called. One witness stated the family was asked if they wanted life support and said yes, while another witness stated the resident’s spouse and son were present and that the spouse was removed from the room. The regional nurse confirmed CPR was initiated when it should not have been because the resident had a DNRCCA order. The DON stated staff believed someone was sent to verify the code status while the code continued, and the respiratory therapist stated she did not have time to look in the chart before starting compressions. The facility also failed to ensure advance directive documentation was accurate in the medical record for another resident. Resident #28 had physician orders and a care plan indicating DNRCCA, but the record did not contain signed documentation verifying that status in the hard chart. A review of the electronic chart showed DNRCCA, while the regional nurse stated there was no signed code status paper in the medical record and reported that the resident had said he wanted to be a full code. The facility policy required advance directives to be maintained in the medical record and readily retrievable, and to be followed.
Ambu Bag Not Readily Available During Code Blue
Penalty
Summary
The facility failed to ensure the immediate availability of essential emergency resuscitation equipment for a resident who was designated Full Code during a Code Blue event. When the resident was found unresponsive and not breathing, staff initiated CPR, but an ambu bag was not readily available at the start of the emergency. Staff instead used a non-rebreather mask, and one nurse asked for an ambu bag to be brought from another floor. The resident’s code was documented as having been initiated immediately, with CPR continuing until EMS arrived and took over. Interviews confirmed that staff observed the ambu bag was not in use and was not readily available when the code began. A nurse stated that chest compressions were being performed when he arrived, but there was no ambu bag in use. Another nurse said staff were looking for the ambu bag and that it was not readily available at the start of the code, though one was brought in before EMS arrival. The DON stated that staff were expected to respond immediately with all necessary equipment, including an ambu bag, oxygen, and an IV starter kit, and acknowledged that a non-rebreather mask does not replace an ambu bag. The crash cart stock list identified one ambu bag on top of the cart, and the facility’s CPR policy stated that emergency basic life support should be provided immediately, including CPR, in accordance with physician orders and advance directives.
Failure to Provide Ventilations During Code Response
Penalty
Summary
The facility failed to provide basic life support to a resident with full code status when the resident became unresponsive and was found without vital signs. The resident had Huntington's disease, dysphagia, anxiety, gastrostomy status, severe cognitive impairment, and was dependent on staff for all activities of daily living. The care plan and physician orders reflected full code status, with CPR to be initiated in the event of a cardiac or respiratory event. On the evening of the event, staff identified the resident as unresponsive after dinner. LPN #200 checked the resident, found no vital signs, and began chest compressions after checking code status and bringing the crash cart to the room. However, staff did not immediately call 911; the call was made only after compressions had already started. EMS records showed the 911 call was received at 8:06 P.M. and EMS arrived at 8:18 P.M. When EMS arrived, staff were performing chest compressions without ventilations. EMS documented that the resident had been without ventilations for greater than 12 minutes and then initiated ventilations with a bag valve mask while continuing resuscitation efforts. Interviews and record review showed that LPN #200 and LPN #216 performed chest compressions only and did not provide rescue breathing or ventilations during the code. LPN #200 stated the bag valve mask was not used because staff did not know how to use it and believed it was not on the crash cart, although the cart audit logs and observation showed bag valve masks and CPR mouth shields were present. The DON stated that if a code occurred, staff should call 911, apply the AED, and have one nurse provide ventilations while another performed compressions. EMS later pronounced the resident deceased after resuscitation efforts were stopped by physician direction.
RN lacked CPR certification with hands-on skills validation
Penalty
Summary
The facility failed to ensure that RN 2 maintained current CPR certification from a CPR provider whose training included a hands-on session in accordance with accepted national standards. During employee file review with the DSD, RN 2’s BLS certification was found to have been obtained from an online CPR provider, and the DSD stated she did not know whether the certification was entirely web based without the required in-person hands-on component. RN 2 later stated that the BLS course she completed was entirely online and consisted of reading materials, watching videos, and answering questions, with no hands-on component or requirement to demonstrate CPR skills. During a later interview, the DSD stated RN 2 needed to obtain BLS certification that included a hands-on component where skills are validated, and said this was necessary to ensure staff competency in performing CPR. Review of the facility’s CPR policy showed that staff were to maintain current CPR certifications through a provider whose training included a hands-on session in a physical or virtual instructor-led setting in accordance with accepted national standards, and that online knowledge components were acceptable only when in-person skills demonstration was also required.
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