F0678

J

Failure to Honor Full Code Status Due to Conflicting Documentation and Omission of CPR

Appleton City, Missouri Survey Completed on 02-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide care consistent with a resident’s advance directives and physician orders when staff did not initiate CPR for a resident who was a full code. The resident’s medical record contained conflicting documentation regarding code status: page one of the face sheet listed DNR, while page two listed CPR in the advance directive field. The resident’s current physician’s order sheet contained an order for CPR, and the health care directive form, signed by the resident’s guardian, indicated that the guardian did not wish to make a health care directive at that time, which staff stated defaulted to full code. The Social Services Director and nursing staff reported that, in the absence of a signed DNR, the resident’s status should be full code and CPR should be initiated if the resident was found unresponsive.

On the day of the incident, a CNA checked on the resident around 6:00 A.M. and observed the resident sleeping. When the CNA returned around 7:45 A.M. to assist the roommate, the resident was found lying across the bed, appearing as if they had attempted to sit up and then slumped over, and did not respond. The CNA called for the nurse and then checked the emergency book, which indicated the resident was DNR. RN E responded, found the resident lying across the bed with no heartbeat or respirations, lips blue, and a gray appearance, and did not initiate CPR. RN E instead notified the Administrator, and together they pronounced the resident deceased at 7:55 A.M. without starting CPR. Nursing progress notes documented that the resident was found unresponsive at 7:50 A.M., with ashen face and purple lips, and that the resident was pronounced deceased at 7:55 A.M.

Multiple staff interviews revealed inconsistent understanding and use of code status information. Staff reported that code status could be found in several locations, including the emergency binder, the electronic medical record, the resident’s door tag (red sticker for DNR), and the face sheet. LPNs, CNAs, the MDS Coordinator, and the SSD stated that if there was no signed DNR or if code status information conflicted, the resident should be treated as full code and CPR should be started and continued until EMS arrived. The DON, SSD, NP, Medical Director, and Administrator all confirmed that the resident’s health care directive and physician orders supported a full code status and that the resident’s code status should have been consistent throughout the record. Despite this, RN E and the Administrator relied on the DNR notation on the face sheet and the emergency book and did not question the discrepancy or initiate CPR when the resident was found unresponsive.