Failure to Verify and Honor Resident DNR Prior to Initiating CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s Do Not Resuscitate (DNR) order by not verifying code status before initiating life-saving measures. The resident was an older male with multiple significant diagnoses, including cerebral infarction, muscle weakness, hyperlipidemia, type 2 diabetes without complications, quadriplegia, acute posthemorrhagic anemia, and hypotension. His care plan documented that he was DNR, and an intervention required staff to check the resident’s file for DNR status before calling a code. During routine rounding, a nurse observed the resident gasping for air, sweating profusely, and then becoming unresponsive. A code was called, life-saving measures were initiated, and 911 was contacted. Cardiopulmonary resuscitation (CPR) and other life-saving interventions were provided by LVN A and then continued by emergency medical services (EMS) upon their arrival, before the resident’s DNR documentation was located and confirmed as active. Interviews and record reviews showed that facility policy required staff to determine whether a resident had a DNR in place before taking any life-saving measures. The Administrator, ADON, and nursing staff stated that the nurse who calls a code is responsible for verifying DNR status prior to initiating CPR, and that failing to do so violates facility policy. The facility’s provider report documented that the nurse on duty failed to comply with the resident’s DNR by calling a code and initiating life-saving measures despite the DNR order being in place.
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