Failure to Honor DNR Order Resulting in Inappropriate CPR
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services met professional standards of quality by not honoring a resident’s documented Do Not Resuscitate (DNR) status. The resident had a Massachusetts Medical Orders for Life Sustaining Treatment (MOLST) form, signed by the resident, indicating DNR, Do Not Intubate (DNI), and transfer to the hospital, and corresponding physician’s orders also documented DNR/DNI. Facility policy on Cardiopulmonary Resuscitation (CPR) required staff to provide basic life support, including CPR, in accordance with the resident’s advance directives. The resident, admitted with diagnoses including left hip fracture, diabetes, chronic kidney disease, morbid obesity, and high cholesterol, was found unresponsive in the evening when the assigned nurse entered the room to administer scheduled medications. The assigned nurse called for help, and when asked by the unit manager about the resident’s code status, the nurse stated the resident was a full code, relying on information from another nurse and without checking the physician’s orders or MOLST. The second nurse, who had also responded, assessed the resident as unresponsive, not breathing, and without a pulse, and accepted the assigned nurse’s statement that the resident was full code without independently verifying the code status. Based on this incorrect information, the unit manager initiated CPR, including chest compressions and application of an Automated External Defibrillator (AED), and two rounds of 30 chest compressions were performed. While CPR was in progress, the second nurse reviewed the resident’s MOLST and discovered the resident’s DNR/DNI status. CPR was then discontinued after the MOLST was confirmed to belong to the resident. The Director of Nurses later stated that staff should have verified the resident’s code status before initiating CPR, but they did not, resulting in resuscitative efforts being performed contrary to the resident’s documented advance directives.
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