F0578

D

Failure to Honor Resident DNR/DNI Due to Lack of EMR Documentation and Chart Review

West Hartford, Connecticut Survey Completed on 03-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to honor a resident’s documented advance directive specifying Do Not Resuscitate/Do Not Intubate (DNR/DNI). The resident was admitted with diagnoses including peripheral vascular disease, cellulitis of the left lower limb, and an unspecified open wound of the left lower limb, and could ambulate with assistance using a four-wheel walker. A “Current Consent for Life Sustaining Procedure” form, located in the resident’s paper chart and signed by both the resident and the Medical Director, documented the resident’s refusal of CPR, artificial respiration, and artificial nutrition. However, this DNR/DNI status was not entered into the electronic medical record. When the resident was later found unresponsive and pulseless on the toilet by a nursing assistant, LPN staff responded assuming the resident was a full code.

LPN staff initiated CPR and a code blue was called without first checking the resident’s paper chart for advance directives. One LPN began compressions and another LPN took over CPR after being informed the resident was a full code. CPR continued until EMS arrived and reviewed the resident’s medical records, at which point EMS informed staff that a DNR/DNI order existed in the paper chart. CPR was then stopped and the resident was pronounced deceased. The DNS confirmed that the resident’s advance directives were not followed because the LPN did not review the paper chart, and the facility was unable to provide an advance directive policy. The facility’s existing CPR/AED policy stated that CPR should be initiated unless a valid DNR order was in place or other specific conditions existed, but the resident’s valid DNR/DNI order was not identified or honored at the time of the event.