Failure to Verify DNR Status and Inconsistent Code Response Practices
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff were educated and equipped to respond appropriately to a resident’s change in condition, specifically regarding verification of code status, CNA involvement in CPR, and use of code documentation tools. Record review showed that Resident #1 had a signed Do Not Resuscitate Order (DNRO) on file, and hospital records uploaded into the facility’s system documented the resident’s code status as Do Not Resuscitate on two separate dates, with no evidence that this order had been rescinded. The facility’s own physician orders also showed a DNR order initiated for this resident. Progress notes documented that Resident #1 experienced a change in condition at the facility, during which an RN assessed the resident, who then stopped breathing and was reported to have no pulse. The RN directed an LPN and a CNA to place the resident on the floor and begin chest compressions. The CNA stated that CNAs were not allowed to perform CPR at the facility, and LPN staff continued CPR until EMS arrived and took over. Interviews with the Nursing Home Administrator and regional leadership confirmed that the involved staff did not verify the resident’s code status prior to initiating CPR, despite the resident’s documented wishes not to be resuscitated. Multiple staff interviews revealed inconsistent understanding of the facility’s code procedures, the role of CNAs in CPR, and the use and availability of code blue forms or timelines. The NHA stated that CNAs were not allowed to perform CPR and that if CPR was started, the code should be documented using paper attached to the crash cart, but acknowledged that staff did not use this documentation during the event. Some LPNs reported that code sheets or timelines were supposed to be on the crash cart, while others stated they had never seen a code blue log or were unaware that a code timeline was used. CNAs expressed uncertainty about whether they were allowed to perform CPR, and one CNA referenced a book at the desk listing residents’ code statuses. Review of the facility’s Quality Management/QAPI policy showed that the facility’s QAPI program was intended to use data and systemic analysis to improve care, but the events described demonstrated that staff were not consistently following or aware of established processes related to code status verification and code response documentation.
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