Failure to Honor Resident DNR Resulting in Unwanted CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s advance directive and DNR (Do Not Resuscitate) order when the resident was found unresponsive. The resident had been initially admitted with diagnoses including osteomyelitis of the left hand and recurrent major depressive disorder. The medical record contained a Code Status-Elective Form signed by the resident and the attending physician indicating a DNR status, explicitly stating that no one should attempt resuscitation if the resident’s heart and breathing stopped. A physician’s order and a social services evaluation also documented that the resident had an advance directive specifying DNR status, with copies of the directive present in the chart. On the date of the incident, an incident/accident note documented that the resident was found unresponsive on the bathroom floor with no respirations and no palpable pulse, and a pipe and cigarette lighter with an unknown substance were observed nearby. Staff initiated a Code Blue and began CPR at 23:03, completing five rounds of chest compressions. The note states that the resident regained spontaneous respirations and a palpable pulse prior to EMS arrival, remained unresponsive but breathing spontaneously, and was then transferred to an acute care hospital for a higher level of care. Interviews with staff confirmed that the resident’s DNR status was not checked before CPR was started. The nurse supervisor who performed CPR reported that they did not verify the resident’s code status, assuming the primary nurse had already done so, despite stating that the nursing standard was to quickly verify code status before initiating CPR. The resident’s nurse at the time of the event also acknowledged that they did not verify the code status before the team started CPR and later learned the resident was DNR and should not have received resuscitation. The DON confirmed that issues were identified with the CPR process for this resident and that nursing staff failed to check the advance directive before performing CPR, resulting in resuscitation being carried out contrary to the resident’s documented wishes and legal DNR order.
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