Failure to Honor DNR Order and POLST During Cardio-Pulmonary Arrest
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s documented wishes to withhold life-sustaining treatment, including CPR, as specified in a POLST and physician order for Do Not Attempt Resuscitation (DNR). The facility’s policy on Basic Life Support and Cardiopulmonary Resuscitation, revised 10/2017, states that resident wishes expressed in an advance directive or POLST, including DNR orders, are to be honored and that a DNR order indicates the resident should not be resuscitated if respirations and/or cardiac function cease. The resident in question was admitted without capacity to make medical decisions and had a POLST form signed by the legally recognized decision maker indicating DNR, as well as a physician’s order for DNR documented on the Order Summary Report. Despite these orders, when the resident became unresponsive and pulseless, staff initiated and continued CPR. A CNA reported that while accompanying the resident in his room, the resident became unresponsive within approximately five minutes; the CNA checked for a pulse, found none, and immediately began CPR while calling for help. An RN responded to the emergency, assessed the resident, confirmed absence of a pulse, and provided CPR, later acknowledging awareness that the resident had a DNR order and stating she should have verified the code status by checking the Physician Order Summary Report and POLST form. An LVN also participated in providing CPR without verifying the resident’s code status and stated that CPR should not be initiated when a DNR order is in place. The Administrator and DON were informed of and acknowledged these findings.
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