Failure to Implement and Honor Resident DNR Order Resulting in Full Resuscitation
Penalty
Summary
The deficiency involves the facility’s failure to obtain, process, and implement a resident’s advance directive and DNR order in a timely manner, and the subsequent failure to honor the resident’s DNR status during a cardiac arrest. The resident was admitted on hospice services with a diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris and was cognitively independent, able to make consistent and reasonable decisions. On admission, the facility did not complete consent forms, including advance directives and DNR paperwork, as confirmed by the DON during an admission audit conducted days later. The facility’s own policy required determination of advance directives on admission and completion of a DNR order form signed by the attending physician and resident, to be placed in the front of the medical record and scanned into the electronic record. The DON reported that after discovering the missing consents during the admission audit, she had an LPN meet with the resident to complete the consents, including the DNR form. The resident, who was her own responsible party, signed the facility DNR form in the presence of the DON and the LPN, and the form was later signed by the physician. The DON emailed the DNR form to the medical director for signature and received the signed DNR back in her individual email inbox at 3:37 PM on the day of the code event. However, the DON was not working that day, did not check her email, and no one else had access to that inbox. As a result, the signed DNR form was not retrieved, the resident’s code status in the electronic medical record was not updated from “Full Code” to “Do Not Resuscitate,” and the DNR form was not placed or scanned into the resident’s record prior to the code event. Later that evening, the resident was found unresponsive on the bathroom floor by an LPN, who checked the code status in the physician’s orders and saw it listed as “Full Code.” Based on that information, staff initiated CPR, brought the crash cart and AED, and called EMS. The facility’s Code Blue documentation and EMS records show that CPR, AED use, airway management, administration of epinephrine, IV fluids, and intraosseous access to the tibia were performed in an attempt to resuscitate the resident, and the resident was later pronounced deceased. The resident’s family member reported that the resident had completed DNR paperwork with the admission nurse on the first day of admission and that hospice had sent preadmission screening documents indicating the resident’s wish to be DNR. The family member expressed concern that the resident’s advance directives and end-of-life care were not honored and that the resident underwent a code despite her stated wishes.
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