Failure to Honor Resident’s DNR/DNI Orders Before Initiating CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s documented Do Not Resuscitate (DNR) and Do Not Intubate (DNI) status when the resident was found unresponsive. The resident had a Massachusetts Medical Orders for Life Sustaining Treatment (MOLST) form, signed by the resident, indicating DNR/DNI and transfer to the hospital, and corresponding physician’s orders also documented DNR/DNI. On the evening in question, the resident, who had diagnoses including left hip fracture, diabetes, chronic kidney disease, morbid obesity, and high cholesterol, was found unresponsive in their room by the assigned nurse while the nurse was bringing scheduled medications. The nurse called for help, and additional nursing staff, including a unit manager and another nurse, responded. When the unit manager asked about the resident’s code status, the assigned nurse stated the resident was a full code, based on what another nurse in the room said, without checking the physician’s orders or the MOLST. The second nurse reported that she had asked the assigned nurse about the code status and was told the resident was a full code; she also did not verify this against the resident’s records. Relying on this incorrect information, the unit manager initiated CPR, including chest compressions and application of an Automated External Defibrillator (AED), and two rounds of chest compressions were performed. While CPR was underway, the second nurse reviewed the resident’s MOLST, discovered the DNR/DNI status, and informed the team, at which point CPR was discontinued. The Director of Nurses later stated that staff should have verified the resident’s code status before initiating CPR, but they had not.
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