F0678

J

Failure to Honor DNR Resulting in Unwanted CPR and Life-Sustaining Measures

Grand Rapids, Michigan Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to honor a cognitively intact hospice resident’s clearly expressed wish to be Do Not Resuscitate (DNR), resulting in CPR and other life-sustaining interventions being performed. The resident was admitted on hospice services with diagnoses including atherosclerotic heart disease with unstable angina, lung cancer, heart failure, and a history of malignant neoplasm of the bronchus and lung. Pre-admission hospice documentation faxed to the facility and uploaded into the electronic medical record before admission indicated the resident’s care type as hospice and explicitly listed “DO NOT RESUSCITATE” in the clinical information. The resident’s hospice care plan also stated that the goal was for the resident’s end-of-life wishes to be honored.

On the day of admission, the resident, who was documented as cognitively independent and responsible for her own decisions, completed the facility’s DNR form expressing that no one should attempt resuscitation if her heart and breathing stopped. Family members present at admission confirmed that the resident completed and returned the DNR paperwork to the nurse doing the admission, and that hospice had already communicated the resident’s DNR status to the facility. However, the facility later could not locate any advanced directive or DNR forms for the resident during an admission audit. The DON confirmed that consent forms, including advanced directives and DNR, were supposed to be completed on day 1, but for this resident the DNR was not found and was not in place as required.

Several days after admission, when the missing DNR was discovered, the DON and an LPN again completed a DNR form with the resident, who remained her own responsible party. This DNR form was signed by the resident and two witnesses and then emailed by the DON to the medical director for physician signature. The physician signed the DNR and returned it electronically to the DON’s individual email inbox approximately seven hours before the resident experienced a code event. The DON, who was not working and was the only person with access to that inbox, did not retrieve the signed DNR, and the resident’s electronic physician orders were never updated from “FULL CODE” to DNR. As a result, when the resident was later found unresponsive on the bathroom floor without a pulse, the LPN checked the physician orders, saw “FULL CODE,” and initiated CPR, used an AED, and called EMS. EMS continued resuscitative efforts, including defibrillation, airway placement, and intraosseous access, until the resident was pronounced deceased. The facility’s own documentation and family interviews confirmed that CPR and other life-sustaining measures were performed despite the resident’s documented and repeatedly communicated wish to be DNR, and that the failure to timely complete, retain, and implement the DNR documentation led directly to the provision of unwanted resuscitative care.

Removal Plan

• Completed a blanket audit of residents to ensure the medical record accurately reflects each resident’s code status and that a signed copy of the advance directive is uploaded into PCC; no concerns or corrections noted.
• Reviewed the CPR and Advanced Directive policy by the NHA and DON and determined it remains appropriate.
• Had the Social Service Director audit all residents to ensure proper code status is in place; no changes required.
• Completed a DON audit of admissions to ensure proper code status is in place for new admissions; no discrepancies noted and no corrections made.
• Reviewed the admission policy and deemed it appropriate.
• Educated all licensed nurses on completing advanced directives paperwork on admission with the designated responsible party and notifying the physician to obtain orders and place into PCC.
• Implemented a process requiring the admitting nurse to meet with the resident/responsible party immediately upon admission to address code status wishes, complete the paperwork, and immediately communicate with the physician to obtain orders for entry into PCC.
• Implemented a process for immediate action on code status documentation: the admitting nurse faxes the document to a preprogrammed fax number that transmits to the provider email; the provider signs and returns via provider phone to facility fax; nurses also call the provider to alert them of the incoming document.
• Initiated weekly DON audits to ensure new admissions’ code status documentation is obtained/completed by the admitting nurse and that facility procedure/policy is followed, continuing until QAPI determines substantial compliance is achieved.