Failure to Ensure Valid DNRO Resulted in Unwanted CPR
Summary
The deficiency involves the facility’s failure to honor a resident’s Do Not Resuscitate (DNR) wishes by not ensuring those wishes were completely and accurately documented to promote continuity of care between providers. The resident, an older male admitted with stroke, type 2 diabetes, essential hypertension, HIV, unspecified dementia, heart failure, coronary artery disease, renal insufficiency, and non-Alzheimer’s dementia, had a physician order for DNR in the electronic medical record (EMR). His Minimum Data Set assessment showed moderate cognitive impairment, and his care plan included impaired cognitive process with an intervention to communicate with the resident and family regarding his needs. The hospital transfer documentation (3008 form) indicated the resident was DNR, and a Florida Do Not Resuscitate Order (DNRO) form signed by the hospital physician was present in the EMR. On the night of admission, the LPN Supervisor reported that the resident was confused, so she and another nurse contacted the resident’s daughter by phone for consent to treat and to confirm his DNR status. They confirmed with the daughter that the resident’s wish was to be DNR and signed the facility’s Advance Directives Discussion Document, but they did not sign off on the Florida DNRO form. The Social Services Director (SSD) later reviewed the admission packet and noted that the Florida DNRO form was signed only by a physician and lacked any other signature. The SSD stated that she, the former DON, and the former ADON called the resident’s daughter to verify his wish not to have CPR, and confirmed that the two nurses on the call were RNs. However, the SSD could not explain why the nurses did not document this conversation, did not sign the Florida DNRO form until the resident or proxy could sign, and did not obtain the necessary signature by another means. On the morning of the resident’s death, the assigned RN reported that a CNA notified her that the resident was unresponsive at approximately 5:45 AM. The RN assessed the resident, found no blood pressure, pulse, or respirations, and confirmed in the EMR that the resident’s code status was DNR. She then called EMS and, upon their arrival, provided them with a printed copy of the Florida DNRO form, which she located on goldenrod-colored paper in the front office. EMS personnel observed that the form contained only the physician’s signature and lacked the resident’s or authorized representative’s signature, and informed the RN that the form was invalid. EMS then initiated CPR and continued until they discontinued efforts and pronounced the resident deceased. The resident’s daughter later confirmed she was his health care proxy, stated she had informed facility staff at admission that he was DNR, and was later told by facility staff that EMS performed CPR because the Florida DNRO form was not signed. The facility’s own policies required complete, accurate, and timely documentation of residents’ treatment choices and advance directives, but the necessary signatures and documentation for a valid Florida DNRO were not obtained or made available, leading to the failure to honor the resident’s DNR wishes.
Removal Plan
- Notify the attending physician, Medical Director, Administrator, interim DON and resident representative of the incident and initiate an investigation.
- Conduct an immediate 100% audit of all current residents' code status and care plan; verify the presence of a valid Florida DNRO form for each applicable resident in the EMR; confirm the form contains the physician and resident/proxy signatures, signature dates, and legal proxy authority; and contact attending physicians and legally authorized representatives to complete any missing or incomplete Florida DNRO form documentation.
- Print the Florida DNRO form for each applicable resident and place it in Emergency Response Binders.
- Place Emergency Response Binders on each unit, in the rehabilitation (therapy) room, and in social services.
- Initiate advanced directives audits weekly for three months to ensure the Florida DNRO form is complete and valid.
- Implement a revised admission/readmission process that includes Resident Rights and Advance Directive education upon admission, completion of an Advance Directives Discussion Document, and validation of advance directives by Social Services/designee.
- Provide education to licensed nurses, the Social Services Director, and the Admissions Coordinator on the location of goldenrod (yellow) paper for printing Florida DNRO forms.
- Provide education to licensed nurses, the Admissions Coordinator, and the SSD on documentation in the medical record to ensure each resident's medical record contains complete, accurate, and timely documentation.
- Educate the SSD on ensuring accuracy of advance directives and the Florida DNRO form.
- Implement a Florida DNRO form admission and readmission checklist to ensure verification of required signatures, confirmation of proxy authority, proper form completion, and physical availability of the Florida DNRO form.
- Hold an Ad Hoc QAPI committee meeting.
- Complete a 100% chart audit of advanced directives including code status, DNR orders, and Florida DNRO forms.
- Educate all licensed nurses on Resident Rights related to Advanced Directives, verification of advance directives, DNR orders, Florida DNRO forms and requirements, and complete and accurate documentation in the EMR.
- Require completion of a post-test following education to ensure understanding.
- Continue education for new employees.
- Hold Ad Hoc and monthly QAPI meetings with the Administrator, Director of Nursing, Medical Director, and administrative staff.
- Review and revise education, audits, and post-tests as indicated.
- Conduct staff interviews representing all shifts to assess knowledge of advanced directives, verification of code status, completion of the Florida DNRO form, and location of Emergency Response Binders.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Incomplete DNR Forms for Two Residents: Two residents with DNR status had incomplete DNR paperwork. One resident with CKD and severe cognitive impairment had no resident signature on the DNR form, and the physician signed on the wrong line. Another resident with Alzheimer’s disease and severe cognitive impairment had the resident signature on the proxy line, but the physician signature, date, printed name, and license number were missing. The SW and ADM verified the forms were not completed correctly.
Incomplete DNR forms were found for two residents with DNR status. One resident with chronic respiratory failure, heart failure, and type 2 diabetes had a DNR form with the resident’s signature on the wrong line and an undated physician signature, and another resident with renal disease and type 2 diabetes had the resident’s signature on the wrong line with the Person’s Signature line left blank. The DON and SW both verified the missing information and stated the forms were not completed correctly.
Failure to Review Residents’ AD Decisions: The facility did not ensure that 3 residents were informed of and had their AD decisions reviewed. Each resident was able to make needs known and was their own responsible party, but the EHR did not show review of AD decisions on admission or at care conferences. The Social Services Director and Administrator both acknowledged the missing reviews.
A resident with CHF, pulmonary edema, and chronic respiratory failure had care plan and IDT documentation stating an Advance Directive was on file and up to date, but the document could not be found in the record. The ADON stated only a POST form was present, confirmed a POST is not an Advance Directive, and said there was no copy of the resident’s Advance Directive on file.
Failure to Assist Residents With Advance Directive Formulation: Multiple residents had no advance directive in the chart or documented follow-up after social services notes showed they either already had a POA/Living Will or wanted help completing one. Residents with conditions including fx, chronic resp failure, delirium, sepsis, HTN, CKD, AFib, UTI, discitis, and anemia had incomplete documentation, and one care plan had conflicting POA/Living Will information.
Incomplete OOH-DNR Documentation: A resident with severe cognitive impairment, dementia, HTN, CAD, and dysphagia had DNR status documented, but the OOH-DNR form was not fully completed. The form was signed by the qualified relative, yet the attending physician did not sign the required section and the document lacked the physician's dated signature, printed name, and license number; the DON stated the form was still valid based on the witness signature date.
Incomplete DNR Forms for Two Residents
Penalty
Summary
The facility failed to ensure that two residents with documented DNR status had properly completed DNR forms. One resident was a male admitted with chronic kidney disease and acute cystitis with hematuria; his face sheet and physician order summary both reflected DNR status, and his MDS showed severe cognitive impairment with a BIMS score of 6. His DNR form dated 8/06/24 did not contain the resident’s signature, and the physician signed on the line intended for the resident’s signature. The second resident was a female admitted with Alzheimer’s disease and chronic kidney disease; her face sheet and physician order summary also reflected DNR status, and her MDS showed severe cognitive impairment with a BIMS score of 3. Her DNR form dated 09/25/25 had the resident’s signature on the line for a legal guardian, agent, or proxy, but the physician’s signature, date, printed name, and license number were missing. The social worker and administrator both verified the missing information and stated the forms were not valid if not completed correctly.
Incomplete DNR Forms for Two Residents
Penalty
Summary
The facility failed to ensure that two residents with DNR status had completed DNR forms with all required information. Resident #9, a male with chronic respiratory failure, heart failure, and type 2 diabetes, had a DNR order on the physician order summary and a care plan for DNR, but the DNR form showed the resident’s signature on the line for Guardian/Agent/Proxy/Relative Signature, the Person’s Signature line was blank, and the physician’s signature was not dated. Resident #35, a male with renal disease and type 2 diabetes, also had a DNR order and a care plan for DNR, but the DNR form showed the resident’s signature on the line for Guardian/Agent/Proxy/Relative Signature and the Person’s Signature line was blank. During interviews, the DON stated the DNR was not valid if it was not filled out correctly and verified the missing information on the forms for Residents #9 and #35. He stated the SW was responsible for making sure the DNR was completed accurately and that quarterly audits of DNRs were completed for accuracy. The SW also verified the missing information on the DNR forms for both residents and stated she and the resource nurses were responsible for ensuring DNRs were completed correctly. The facility’s Social Services policy stated advance directives would be recognized and respected and that the facility would implement residents’ decisions and directives in compliance with state and federal law and facility policy.
Failure to Review Residents’ Advance Directive Decisions
Penalty
Summary
The facility failed to ensure that residents were informed of their right to establish an advance directive for 3 of 3 sampled residents reviewed for advance directives. Resident 6 was admitted with diagnoses including COPD and diabetes, was able to make needs known, and was their own responsible party, but the electronic health record did not show that the facility reviewed the resident’s advance directive decisions. Resident 11 was admitted with diagnoses including metabolic encephalopathy and diabetes, was able to make needs known, and was their own responsible party, but the record also did not show review of advance directive decisions. Resident 141 was admitted with diagnoses including acute kidney failure and diabetes, was able to make needs known, and was their own responsible party, but the record did not show review of advance directive decisions. During interviews, the Social Services Director stated that residents’ advance directive decisions should be reviewed on admission, at quarterly care conferences, and at the resident’s request. The Social Services Director later stated that Resident 6’s most recent care conference on 02/24/2026 did not include review of the advance directive decision, Resident 11’s initial care conference on 04/07/2026 did not include review, and Resident 141’s most recent care conference on 11/17/2025 did not include review. The Administrator also stated that social services would review advance directive decisions with residents on admission and at quarterly care conferences, and acknowledged that the lack of review for Residents 6, 11, and 141 did not meet expectations.
Advance Directive Not Located in Resident Record
Penalty
Summary
The facility failed to ensure residents exercised their right to formulate an Advance Directive for Resident #33. The State Operations Manual defines an Advance Directive as a written instruction such as a living will or durable power of attorney for health care, and distinguishes a POLST form from an Advance Directive. Resident #33 was readmitted with multiple diagnoses including congestive heart failure, pulmonary edema, and chronic respiratory failure. Resident #33’s care plan, initiated on 5/4/26 and revised on 5/18/26, documented that the resident had an Advance Directive on file and that it was up to date. An IDT Conference Note dated 5/12/26 also documented that the resident’s Advance Directives were reviewed, accurate, and up to date. However, the resident’s Advance Directive could not be located in the record. On 5/28/26, the ADON stated she only saw the resident’s POST form, acknowledged that a POST form is different from an Advance Directive, and stated she did not believe Resident #33 ever gave the facility an Advance Directive; she confirmed there was no copy on file.
Failure to Assist Residents With Advance Directive Formulation
Penalty
Summary
The facility failed to ensure residents and their representatives received assistance to exercise their right to formulate an Advance Directive. Based on policy review, record review, and staff interview, 9 of 12 reviewed residents did not have an advance directive in the medical record or documentation that advance directive information was provided, discussed, or followed up on with the resident or representative. The facility policy stated that on admission the facility would determine whether the patient had executed an advance directive and, if not, determine whether the patient would like to formulate one. Several resident records showed social services notes documenting that the resident either already had a POA/Living Will or wanted assistance obtaining one, but the records did not contain the actual advance directive or documented follow-up. Resident #2, admitted with a nondisplaced left femur fracture and chronic respiratory failure, stated he had a POA/Living Will and that the facility could obtain a copy, but the record did not show an advance directive or follow-up. Resident #37, admitted with a displaced intertrochanteric fracture and delirium, stated she did not have one and wanted assistance making one, yet the record did not document the completed directive at the time of review. Resident #60, with diabetes and anxiety, and Resident #66, with acute embolism/thrombosis and anemia, both stated they had advance directives and would have family provide copies, but no copies or follow-up documentation were present. Additional records also lacked required documentation. Resident #61, with multiple rib fractures and atrial fibrillation, had no advance directive documented and no social services note showing the resident was asked about one or offered assistance. Resident #3, with UTI and discitis, had a social services note indicating she had a POA/Living Will and would let family know, but no advance directive or follow-up was documented. Resident #17, with sepsis and hypertension, had conflicting documentation in social services and care planning records regarding POA/Living Will status, while the baseline care plan did not address advance directive status. Resident #29, with a fractured pubis and chronic kidney disease, and Resident #52, with a fractured hip and hypertension, also lacked advance directive documentation in the medical record.
Incomplete OOH-DNR Documentation
Penalty
Summary
The facility failed to ensure a resident had a properly completed advance directive for Resident #5, whose electronic face sheet listed Advance Directives: DNR. Resident #5 had diagnoses including unspecified dementia with behavioral disturbance, hypertension, atherosclerotic heart disease with angina, and dysphagia. The quarterly MDS reflected a BIMS score of 0, indicating severe cognitive impairment, and the quarterly care plan noted that the resident's family/representative completed documentation for DNR status and that the code status would be reviewed quarterly and as needed. Record review of the resident's OOH-DNR form dated 12/08/22 showed the form was signed by the qualified relative in section C, but the attending physician did not sign section E, and the form did not include the physician's dated signature, printed name, or license number. Section F, which required all persons who signed above to acknowledge the document was properly completed, was also not signed by the physician. During interview, Social Services stated DNR forms must be filled out completely and said forms may not be valid if the physician's dated signature and license number were missing. The DON stated the form was valid and said they went with the date of the witness signature when the physician's signature was not dated.
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