F0678

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Failure to Honor DNR Order During CPR Event

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

Penalty

No penalty information released

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.