F0726

J

Failure to Verify and Honor DNR Order Before Initiating CPR

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

Penalty

No penalty information released

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.