F0578

D

Failure to Obtain Informed Consent Before Changing Code Status During CPR Event

Traverse City, Michigan Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to obtain informed consent before changing a cognitively intact resident’s code status from full code to DNR. The resident was an adult male admitted with malignant neoplasm of the tonsil and lymph node, dysphagia, and pneumonitis. His EMR showed a physician’s advance directive order for full resuscitation initiated on 11/17, and a BIMS score of 15 on 11/22 indicating intact cognition. An advance directives/CPR consent form signed by the resident on 11/17 documented that he requested CPR in the event of cardiac arrest.

On the morning of 12/7, staff discovered the resident unresponsive. An IDT progress note by the NHA documented that a CNA found the resident unresponsive, RN Q assessed him and believed he was deceased, and later RN M verified the resident’s full code status and initiated CPR at approximately 9:30 AM. Multiple staff, including CNAs and nurses, participated in the code. Witness statements and interviews indicated that during the code, RN Q entered the room and instructed staff to stop CPR, stating that the resident’s code status had changed to DNR and that this direction came from the DON. Staff reported confusion about how the code status had changed and stopped CPR based on RN Q’s statements.

Interviews with the DON and RN Q revealed conflicting understandings of the instructions given during the event. The DON stated she told RN Q that if the resident was a full code, staff should run the code and stop only when EMS arrived or a physician order was received, and denied ordering cessation of life-sustaining efforts. RN Q later acknowledged she misunderstood the DON and also reported that she contacted an on-call provider during the code to change the resident’s status to DNR. A telehealth note by PA BB documented that nursing staff notified her the resident had passed away, that CPR was started, and that the code status was changed to DNR; PA BB stated she changed the code status based on nursing’s report of imminent death and did not address how this could occur without the resident’s consent. NP L stated that such a code status change was impossible without the declarant’s signature, a physician’s signature, and two witnesses, and the report cites the Michigan Do-Not-Resuscitate Procedure Act requirements, underscoring that no proper DNR order process was followed before the code status change.