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:
Lack of Current Gait Belt Competency for RNA: The facility failed to ensure an RNA/CNA with restorative training had current gait belt training and competency for resident transfers and ambulation. The IPN found no current gait belt competency in the employee file, with the last documented training on file being from 2021. The DON stated the facility’s Professional Standards policy required staff to be trained before using equipment, annually, or as needed, and the ADM stated the facility assessment identified the DSD/designee as responsible for staff training and yearly competencies.
The facility failed to maintain documented CNA competency checklists for multiple CNAs. Personnel files for four CNAs lacked evidence of completed skills and techniques competency, and HR confirmed the checklists were not completed. The DON stated there had been a period of about a month when CNA competency checklists were not maintained, despite the facility orientation policy requiring staff to demonstrate competency in all skills needed for their role.
A resident with heart and vascular disease was readmitted with orders to stop Clopidogrel and ASA and start Apixaban, but the RN entered the new orders without removing the discontinued meds. The EMR generated interaction alerts for Apixaban with ASA and Clopidogrel, but the RN did not recognize or address them, and the night RN supervisor did not complete the required secondary review of readmission orders. The resident continued receiving Clopidogrel and ASA for several doses, and the MD identified the error as significant.
A CNA was observed standing over a resident while assisting with breakfast instead of sitting at eye level. The CNA described meal-assistance practices, while the RNS and DON stated that staff are expected to sit at eye level with the resident for dignity and respect. The facility's policy required nursing staff to meet competency requirements and provide residents with a dignified dining experience.
A resident with significant cardiac history had a documented HR of 131 and low BP, but an LPN did not notify a provider or document a repeat assessment for hours. The resident later developed SOB, chest pain, and low O2 sat, was sent to the hospital, and died there the same evening. The report also found an RN competency assessment with multiple below-standard scores that lacked required reassessment and completion documentation.
LPN lacked documented competency for PICC IV medication administration and gave an IV antibiotic through a PICC without checking for blood return before starting the infusion. The resident had an order for Meropenem IV, and the DON confirmed no competency or skills test had been completed for the LPN, despite facility policy requiring IV education and competency before providing IV services.
Lack of Current Gait Belt Competency for RNA
Penalty
Summary
The facility failed to ensure that nurses and nurse aides had the appropriate competencies to care for residents when the Restorative Nursing Assistant (RNA), a CNA with extra training, did not have current training and competency documentation for the proper use of a gait belt for resident transfers and/or ambulation. During interview and record review, the Infection Prevention Nurse stated there was no current gait belt training in the RNA’s employee file and that the last documented gait belt training was dated 11/1/2021. The Infection Prevention Nurse also stated gait belt training was supposed to be completed annually for resident safety so staff would know how to use the equipment properly and prevent possible accidents and harm to residents. During interview and record review with the DON, the facility’s job description for the Director of Staff Development was reviewed, and the DON stated it was an essential function of that role to participate in the annual facility assessment by providing staff analysis, competency reports, and a gap analysis of training requirements, as well as overseeing and maintaining personnel records. The DON also reviewed the facility’s Professional Standards policy and stated it was not followed, explaining that staff were supposed to be trained before using equipment initially upon hire, annually, or as needed. The Administrator reviewed the facility assessment and stated it identified that the Director of Staff Development and/or designee were responsible for providing training and education to newly hired, current, and registry/contract staff, and that skills competencies were completed yearly and as needed.
Missing CNA Competency Documentation
Penalty
Summary
The facility failed to ensure Certified Nursing Assistants had documented competency in the skills and techniques needed to meet residents' needs. Review of personnel files showed that CNA #201, CNA #202, CNA #203, and CNA #205 each had a hire date listed in their records, but their files did not contain a CNA checklist showing competency in skills and techniques. The report states this deficiency had the potential to affect all residents, and the facility census was 65. During interview, Human Resources stated that nursing completed the competency checklist for CNAs and then filed it in the employee personnel record, but verified that CNA #201, CNA #202, CNA #203, and CNA #205 did not have a completed competency skills checklist. The DON stated that due to staffing changes, there was a period of about a month when CNA competency checklists were not maintained. The facility policy titled Orientation stated that departmental orientation would continue until staff demonstrated competency in all skills necessary for their role and to meet resident needs.
Failure to Reconcile Readmission Med Orders and Respond to EMR Interaction Alerts
Penalty
Summary
Licensed nursing staff failed to accurately reconcile and transcribe hospital discharge medication orders for a resident with atherosclerotic heart disease, peripheral vascular disease, anemia, and intact cognition who returned to the facility with a suprapubic catheter and dependence for multiple activities of daily living. The hospital referral report directed discontinuation of Clopidogrel 75 mg and Aspirin 81 mg and initiation of Apixaban 5 mg, but the physician orders entered into the facility record did not include discontinuation orders for Clopidogrel or Aspirin. The resident’s medication administration record showed continued administration of Aspirin for 3 doses and Clopidogrel for 2 doses after those medications should have been stopped. The electronic medication record generated an order note alert identifying drug interaction warnings when Apixaban was added, including interactions with Aspirin and Clopidogrel, but the admitting RN stated she was not aware the system alerted to the potential interaction and did not address it. The Assistant DON stated the facility policy required medication reconciliation by the licensed staff member and a secondary verification of readmission orders by the 11:00 PM to 7:00 AM shift supervisor, but both steps were not followed. The DON stated the readmitting RN was responsible for reconciling the hospital discharge summary with current orders, removing discontinued medications from the active profile, and cross-referencing readmission orders, while the night supervisor was responsible for independently verifying all readmission orders. The newly assigned agency RN supervisor was on only her second shift at the facility and her first 11:00 PM to 7:00 AM shift, and the DON stated the admitting RN was responsible for orienting her to night shift responsibilities, including the required secondary review of readmission orders. The DON further stated there was no formal checklist to ensure shift-specific responsibilities were reviewed, and the required secondary verification was not completed. As a result, the resident continued to receive Clopidogrel and Aspirin after the hospital had discontinued them, and the medical director identified the medication error as significant.
Inadequate CNA Competency During Meal Assistance
Penalty
Summary
The facility failed to ensure nursing staff met the specific competency requirements of their licensure and certification for one sampled staff member, CNA 1, according to the facility's policy titled Competency of Nursing Staff, revised 1/29/2026. During an observation in Resident 2's room, CNA 1 was seen standing over Resident 2 while assisting her with breakfast. When interviewed, CNA 1 stated that when assisting residents with eating, she should make sure the resident swallows, keep the head of bed high, ensure the resident is comfortable, and provide privacy. During interviews, RNS 1 stated that staff should be at eye level with the resident when assisting with eating by keeping the bed at the same height as the staff member and avoiding leaning over. The DON also stated that the expectation when assisting a resident with eating is that staff should be sitting down at eye level with the resident, not standing, for dignity and respect. The facility's Dignity policy stated that residents are to be treated with dignity and respect at all times and that the facility culture supports dignity and respect, including providing a dignified dining experience.
Failure to Recognize and Report Significant Change in Condition; Incomplete Nurse Competency Validation
Penalty
Summary
The facility failed to ensure nurses were competent to recognize and act on a significant change in condition for a resident with extensive cardiac history. The resident had diagnoses including atrial fibrillation, acute diastolic congestive heart failure, takotsubo syndrome, a prosthetic heart valve, and bacteremia. The resident’s care plan noted cognitive intactness, IV antibiotics, a diuretic, and an anticoagulant, with a goal of returning home. A nursing note documented a heart rate of 131 beats per minute and blood pressure of 98/53, but there was no documentation that a provider was notified or that the nurse further assessed the elevated heart rate. Approximately seven hours later, the next clinical entry was from an on-call provider documenting shortness of breath, chest pain, and not feeling well. The provider note included a pulse of 80 and oxygen saturation of 77, but there was no indication the nurse had informed the provider of the resident’s cardiac history, the recent hospitalization for atrial fibrillation with rapid ventricular response, or the earlier heart rate of 131. The record also did not show whether the resident remained stable during the intervening hours or whether the resident was checked during that period. The resident was later sent to the hospital and expired there the same evening. The nurse involved stated that after seeing the pulse of 131, she rechecked the resident and obtained 87, found the resident fine, and did not document the recheck. She stated that later in the evening the resident complained of shortness of breath and heart racing, at which time she assessed the resident and sent the resident out. The nurse’s file contained orientation documentation and a copy of the notification-of-changes policy, but there were no dates or signatures showing when it was reviewed and no evidence of hands-on skills validation. The report also identified that an RN’s competency assessment showed scores below expected standards in multiple skills areas, but the required reassessment and completion documentation were left blank and no further training records were found.
LPN Lacked PICC Line IV Competency
Penalty
Summary
The facility failed to ensure nursing staff were competent to administer IV medications through a PICC line for one resident. The resident had an order for Meropenem 500 mg in sodium chloride 50 mL IV to infuse over 30 minutes. During observation of the medication administration, an LPN cleansed the PICC site, flushed the line with 10 mL of saline, prepared the medication and tubing, attached the tubing to the resident, set the infusion pump, and documented the medication administration in the eMAR. However, the LPN did not check for blood return before starting the infusion, and later confirmed that this was the first time giving the IV antibiotic to the resident since the resident returned from the hospital. Record review showed the facility policy required LPNs to complete IV education and competency with an RN before providing peripheral IV services and on an annual basis, and the nursing procedure reference stated that blood return and catheter patency must be confirmed before initiating infusion through a PICC line. The DON stated there were no competencies completed when the LPN was hired and that no competency skills day had been completed for staff yet that year. The DON also confirmed there was no competency or skills test completed for the LPN in the file, and the MDS Coordinator stated that IV orders were rare and that review with LPNs each time IV medications were ordered would be best.
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