Failure to Verify and Honor DNR Order Before Initiating CPR
Summary
The deficiency involves the facility’s failure to ensure nursing staff were competent in identifying and honoring a resident’s code status and following physician orders for Do Not Resuscitate (DNR). A resident was admitted and later re-admitted with multiple diagnoses including myasthenia gravis, immunodeficiency, COPD, acute pulmonary edema, peripheral vascular disease, history of TIA and cerebral infarction without residual deficits, and adult failure to thrive. The resident had a State of Florida yellow DNR order signed by the resident and physician and scanned into the electronic health record, and there were physician orders in the record reflecting DNR status, including orders that had been changed from full CPR to DNR. On the day of the event, the resident experienced respiratory distress, with staff noting shortness of breath, low oxygen saturation, congestion, and drooling. Nursing staff contacted the provider and obtained orders to transfer the resident to the hospital. As the resident’s condition worsened, multiple staff responded to the room. A crash cart was brought, suction and oxygen equipment were set up, and the resident was suctioned and placed on a non-rebreather mask. The resident was then lowered to the floor and chest compressions were initiated. Staff interviews consistently indicated that no one verified the resident’s code status in the electronic health record or by locating the yellow DNR form before starting CPR. Staff reported that the nurse manager in the room directed the response, including instructing an LPN and CNA to move the resident to the floor and instructing the LPN to begin chest compressions. Several LPNs took turns performing compressions, and staff stated they assumed someone had checked the code status or believed the resident was a full code. The code blue was not called overhead, and the code blue worksheet/timeline on the crash cart was not completed during the event. During the ongoing CPR, another RN arrived, questioned the resident’s code status, and checked the electronic record, confirming the resident had DNR orders. Staff then informed EMS personnel that the resident was DNR and provided the yellow DNR documentation, at which point paramedics discontinued compressions. Facility investigation and timelines showed that chest compressions were initiated at approximately 3:18 p.m., EMS arrived shortly thereafter, and compressions continued until about 3:38 p.m., totaling roughly 20 minutes of CPR on a resident with an active DNR order. Interviews with facility leadership and regional clinical staff confirmed that the process in place at the time relied on staff checking the electronic health record or the presence of the yellow DNR form to determine whether CPR should be performed, but in this incident, staff did not verify the code status before initiating resuscitation. The facility’s own policies on emergency care (CPR), advance directives, admission/readmission, and resident rights required verification and implementation of the resident’s DNR orders, which did not occur in this case. The surveyors determined that this failure to verify and honor the resident’s DNR order resulted in CPR being performed contrary to the resident’s documented wishes and physician orders. The report states that the CPR provided denied the resident the right to a peaceful death and caused unnecessary physical harm and pain. This situation was determined to have created a worsened condition and the likelihood for serious injury and/or death to the resident and led to a finding of Immediate Jeopardy. Cross-references were made to deficiencies related to resident rights, freedom from abuse/neglect, and quality of life (F578, F600, and F678).
Removal Plan
- Initiated disciplinary action/suspension for two nurses; terminated the RN involved and reported the RN to the Board of Nursing.
- Reviewed nurse personnel files and confirmed all nurses had current CPR certification, active license, skills checklists, and background documentation.
- Held ad hoc QAPI meetings to discuss the concern and develop the correction plan, including review of IJ citations.
- Conducted an ad hoc QAPI meeting to plan additional education reinforcing prior education on code status; reviewed and approved a code blue worksheet; reviewed and approved an abuse post-test to reinforce prior education.
- Conducted an ad hoc QAPI meeting to review, revise, and approve the code blue worksheet.
- Deployed the revised code blue worksheet to units and initiated staff review of the worksheet; allowed any staff member to complete the code blue worksheet.
- Provided education to all nurses on advance directives, resident right to make decisions, emergency care (CPR), and abuse/neglect/ANE.
- Educated newly licensed staff upon hire on abuse and code status.
- Completed a review of resident medical records to verify code status orders.
- Audited residents who expired in the facility and found no concerns related to honoring code status.
- Initiated mock code drills on varying shifts and days.
- Reviewed and verified code status for all new admissions.
- Provided reinforcement education to all nurses to verify and document code status orders.
- Implemented the code drill worksheet and added a checkbox for Full Code/DNR based on feedback.
- Provided additional education to non-licensed staff reinforcing prior education on code status, who can perform CPR and emergency care, advance directives, and abuse/neglect/exploitation (ANE) and their role during a code blue.
- Continued ongoing education so staff complete reinforcement education prior to working their next shift.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Insulin Pen Priming Competency Not Verified: An LPN administered Humalog insulin to a resident without priming the Kwik Pen first and stated she was unaware that priming was required. The facility could not produce the nurse's skills check sheet, and the competency form reviewed did not include priming an insulin pen, despite the insulin instructions stating the pen must be primed before each injection.
A facility failed to ensure a QMA had a current license while distributing meds to residents. Record review showed the QMA was scheduled and worked on multiple days across 3 resident units, but the licensure binder and Indiana License Registry showed the QMA's license had expired. The ED stated staff should not distribute meds with an expired QMA license and that the facility had no written policy requiring QMAs to work with a current license.
Missing Mandatory Orientation and Training for Agency CNA: The facility assigned an agency CNA to provide resident care without documentation showing completion of required orientation and in-service training. The CNA stated they did not receive orientation, a training packet, or training on abuse/neglect, dementia care, behavioral health, trauma-informed care, or managing difficult behaviors before working on resident units. The ADON/Staff Educator and DON stated the required training should have been completed and documented in the employee file, but the records could not be located.
CNA Competency Review Completed After Annual Evaluation: The facility failed to ensure that a CNA received a comprehensive clinical competency skills review before the CNA's annual performance evaluation. Record review showed the CNA's annual performance review was completed before the competency review, and the DSD stated she was unaware of the requirement that the skills competency evaluation be completed prior to the annual evaluation.
Incompetent PEG Tube Medication Administration: An LPN was observed administering crushed medication via a resident’s PEG tube but poured the diluted medication directly into the tube without a syringe, causing it to spill. The LPN then did not know how to connect the syringe to the PEG tube and had to call for help, while the DON provided instruction. The resident had diagnoses including an unstageable sacral pressure ulcer, pain, and aphasia following cerebral infarction, and the DON stated the resident did not receive the full dose of medication.
A resident with urinary retention and BPH required a coude catheter, but when the catheter became obstructed, an LPN told the resident to wait until day shift for a change and did not notify the RN supervisor or seek help. Facility records showed no competency training, return demonstration, or skills validation for Foley or coude catheter care, and multiple nurses said they had not received facility-specific education or competency checks for coude catheter management.
Insulin Pen Priming Competency Not Verified
Penalty
Summary
The facility failed to ensure staff possessed the skills and competencies required when a Licensed Nurse administered Humalog insulin to R19 without priming the Kwik Pen first. On 06/02/2026 at 10:13 AM, R19 walked in the hall with a walker, then went to her room with the nurse to receive insulin. The nurse clicked up seven units in the pen and administered the insulin in R19's left arm without priming the pen, and then verified that she had not primed it and stated she was unaware she was supposed to. When the facility was asked for the nurse's skills check sheet, it could not provide it. Review of a blank medication pass competency check sheet showed no competency assessment for priming an insulin Kwik Pen. The insulin pen instructions in the pamphlet directed staff to prime the pen before each injection, and Administrative Nurse D stated she expected staff to prime the insulin pen with two units before administration. She also stated that nurses were required to complete an insulin competency check-off upon hire, and later verified that the nursing skills check lacked a competency item for priming an insulin Kwik Pen.
Expired QMA License During Medication Distribution
Penalty
Summary
The facility failed to ensure that a Qualified Medical Assistant had a current license while distributing medications to residents. A record review showed that QMA 3 was scheduled to distribute medications and had worked as a QMA on multiple days across three resident units from April through the review period. The facility's Employee Certification and Licensure binder showed that QMA 3's license had expired, and the Indiana License Registry website also indicated the license was expired. In interviews, the Executive Director stated that staff should not distribute medications with an expired QMA license and that the facility did not have a written policy requiring QMAs to work with a current license.
Missing Mandatory Orientation and Training for Agency CNA
Penalty
Summary
Certified Nurse Aide #1 was assigned resident care duties on 05/11/2026 as agency staff, but the facility could not provide documentation showing completion of required orientation and mandatory training before the aide worked independently. The missing documentation included, but was not limited to, Abuse/Neglect/Exploitation Prohibition, Behavioral Care Services/Cognitive Impairment/Dementia Training, Trauma Informed Care, Communication Training, and other required orientation and in-service training elements. During the survey, the Assistant Director of Nursing/Staff Educator stated agency staff are required to complete the same mandatory orientation and in-service training as facility staff and that training modules, sign-off documentation, and post-tests are maintained in employee files. However, the facility was unable to locate records verifying that Certified Nurse Aide #1 completed the required training. Certified Nurse Aide #1 stated they did not receive orientation, a training packet, or any of the listed training topics before being assigned to provide resident care on Units 2 and 3. The Administrator also stated that all staff are required to complete mandatory orientation and in-service training prior to working independently and that documentation should have been maintained in the employee file.
CNA Competency Review Completed After Annual Evaluation
Penalty
Summary
The facility failed to implement its policy regarding nursing staff competency by not ensuring that CNA 3 received a comprehensive clinical competency skills review before the CNA's annual performance evaluation. During a concurrent interview and record review on 5/29/2026 at 12:18 p.m., the Director of Staff Development reviewed CNA 3's personnel file, the C.N.A. Comprehensive Clinical Competency Review- Skills Checklist form, and the Annual Performance Review form. The review showed that CNA 3's clinical competency review was completed on 1/22/2026, while the annual performance evaluation was completed earlier, on 12/24/2025. During a concurrent interview and record review on 5/29/2026 at 12:26 p.m., the Director of Staff Development reviewed the facility's policy titled Nursing Staffing Competency and stated she was unaware of the facility's requirement that the annual skills competency evaluation be completed prior to a CNA's annual performance evaluation. The policy stated that the facility will identify annual skills competencies needed for each role and establish a schedule or process to facilitate completion of skills and competency evaluations, and that successfully completed orientation and skills check are required prior to the employee's annual evaluation.
Incompetent PEG Tube Medication Administration
Penalty
Summary
The facility failed to ensure licensed nurses had the necessary competency skills to administer medication via PEG tube for one resident. During an observed medication pass, an LPN prepared crushed medication for the resident’s PEG tube, donned a gown and gloves, stopped the tube feeding, and checked placement and residual. The LPN then poured water and the crushed medication into a 30 ml cup and attempted to pour the diluted medication directly into the PEG tube without using a syringe, causing the medication to spill out over and around the tube. The LPN then obtained another cup with diluted medication and a syringe but did not know how to connect the syringe to the PEG tube, hesitated, activated the call light, and stated they would call for assistance. The DON later entered the room and provided instructional assistance to the LPN on administering medication through the PEG tube. The resident had diagnoses including an unstageable sacral pressure ulcer, pain, and aphasia following cerebral infarction. A physician order directed flushing the PEG tube with 30 ml of water before and after medications and 15 ml between each medication. The LPN stated they were unsure how much medication the resident received when the diluted medication spilled during administration. The DON stated the LPN did not correctly administer the medication via the PEG tube, that the medication was spilled and the resident did not receive the full dose, and that the LPN should have notified the physician. The DON also stated the facility used skills competency checklists upon hire and yearly during a skills fair, but the LPN did not have a skills competency checklist completed upon hire and was past the 90-day timeframe for completion.
Lack of competency validation for coude catheter care
Penalty
Summary
The facility failed to ensure licensed nursing staff possessed and demonstrated the competencies needed to safely assess, manage, and provide care for residents requiring a coude catheter. Resident 9 was admitted with urinary retention and benign prostatic hyperplasia with lower urinary tract symptoms, and a care plan dated March 30, 2026, identified the need for a coude catheter. On May 7, 2026, nurse documentation and interview with the DON showed the resident’s coude catheter became obstructed during the night shift, and the LPN on duty told the resident he would need to wait until day shift staff arrived for the catheter to be changed. The DON stated the LPN reported she was not comfortable changing the coude catheter because of a lack of familiarity and experience with that type of catheter, and she did not notify the RN supervisor or seek assistance to ensure timely catheter intervention. Review of facility documentation titled Skilled Nursing Competency Training showed competencies listed for licensed practical nurses, including nephrostomy tubes and suprapubic catheters, but the facility did not include competency training, return demonstration, or skills validation for Foley catheter insertion, Foley catheter management, or coude catheter care and replacement. During interviews, four licensed nurses stated they had general catheter education in nursing school and prior experience with coude catheters at previous employers, but all reported the facility had not provided facility-specific education, training, competency evaluation, or skills validation related to coude catheter care, evaluation, insertion, replacement, or management. The DON was unable to provide documented evidence that licensed nursing staff had completed education, training, competency evaluations, or demonstrated proficiency for Foley catheter care or specialized coude catheter management.
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