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:
Advance Directive Not Maintained in Resident Record: A resident with dementia, muscle weakness, and protein-calorie malnutrition had documentation indicating an advance directive was in the chart, but record review did not locate a living will or DPOA for health care. The CNO confirmed the record did not include an advance directive and the facility did not have a living will on file.
Incomplete Advance Directive Documentation: The facility failed to keep complete and accurate advance directive records for two residents. One resident's chart contained a representative-signed acknowledgement that did not specify the type of advance directive, and another resident's record had no signed acknowledgement showing that advance directives were discussed. The SSD stated she was responsible for the documentation and that one form was filled out incorrectly while the other resident's paperwork could not be found.
The facility failed to timely respond to changes in condition for two residents, including one with severe cognitive impairment and another with dementia, CHF, diabetes, and a history of UTIs. Family members and DPOAs reported concerns about confusion, agitation, pain, SOB, and other worsening symptoms, but hospital evaluation was delayed while staff waited for physician input. Both residents were later admitted to the hospital with serious infections and other acute conditions, including sepsis, pneumonia, and respiratory failure.
A facility failed to ensure that active physician orders matched residents’ POLST code status for three residents. One resident with COPD, A-Fib, and anxiety had a POLST indicating DNR but no active code status order; another resident with dementia, hypothyroidism, and HTN had a POLST indicating DNR but a physician order for CPR; and a third resident with COPD, respiratory failure, and diabetes had a POLST indicating DNR but no active code status order. The DON confirmed the records were inconsistent and that physician orders and POLST should match.
A resident with dementia with agitation, stroke, and PE had an advanced directive noted in a care conference review, but the document could not be found in the medical record. Staff later confirmed the resident did not have an advance directive on file.
Failure to offer a resident the opportunity to create an advance directive. Record review showed the resident had no advance directive on file, and the SS Director stated there was no documentation that education was provided or that any attempts were made to obtain one. The resident had HTN, CKD, and mild cognitive impairment.
Advance Directive Not Maintained in Resident Record
Penalty
Summary
The facility failed to ensure that a copy of a resident's advance directive was maintained in the medical record for Resident #32, who was admitted with multiple diagnoses including dementia, muscle weakness, and protein-calorie malnutrition. The resident's care plan, revised 5/12/22, documented that the resident and appointed healthcare representative were to receive education regarding advance directives as needed, and a care conference evaluation dated 6/26/26 documented that the resident had an advance directive in the record. However, on 7/8/26, review of the medical record did not locate a living will or durable power of attorney for health care, and the CNO later confirmed that the record did not include an advance directive and the facility did not have a living will on file.
Incomplete Advance Directive Documentation
Penalty
Summary
The facility failed to ensure documentation regarding advance directives was complete and accurate for 2 of 7 residents reviewed. A policy titled "Advance Directives and Refusal of Treatment" stated that upon admission the Social Services Designee should obtain a copy of any existing Living Will, Health Care Proxy, Durable Power of Attorney for Health Care Decisions, or other recorded declaration and enter a progress note regarding the existence of an advance directive. Resident #7 was admitted with diagnoses including hemiplegia and hemiparesis following a nontraumatic intracerebral hemorrhage affecting the right dominant side. The record contained a "Resident Rights & Advance Directive Acknowledgement" signed by the resident's representative that indicated the resident had an advance directive, but the form did not identify the type of advance directive. Resident #81 was admitted with end stage renal disease, and the medical record contained no signed acknowledgement showing that advance directives were discussed with the resident or representative. The Social Services Director stated she was responsible for advance directive documentation, that the form for Resident #7 was filled out incorrectly and should have been corrected, and that the missing paperwork for Resident #81 meant the facility would not know whether the resident had an advance directive.
Delayed Response to Changes in Condition and Family Requests for Hospital Evaluation
Penalty
Summary
The facility failed to timely provide requested medical evaluation and treatment for two residents with changes in condition. The deficiency was identified during review of Complaint #3035494 and involved delayed responses to worsening symptoms, resulting in delayed medical treatment, worsening of condition, and dissatisfaction with care. For one resident with diagnoses including Alzheimer's disease and other medically complex conditions, the record showed severely impaired cognition and inability to make decisions. A family member reported that the resident had a decline in health about a week before hospitalization, with severe UTI and stool impaction. The hospital record documented that the resident arrived from the nursing home via EMS with confusion and altered mental status that had worsened since several days earlier, and the ED physician suspected sepsis. The resident was febrile, tachycardic, had elevated white blood cell count and creatinine, and was diagnosed with proctitis, cystitis, sepsis, NSTEMI, and acute kidney injury. The urine culture was positive for gram-negative rods/Pseudomonas aeruginosa. For another resident with diagnoses including diabetes mellitus, a history of UTIs, CHF, Alzheimer's disease, and dementia, the progress notes showed family concerns about abnormal behavior, confusion, agitation, shortness of breath, congestion, lethargy, and shallow breathing. The resident's DPOA reported repeatedly expressing concern that something was wrong and requesting hospital evaluation, but the facility did not immediately send the resident out and instead contacted the physician first. The change-in-condition documentation noted altered mental status and respiratory symptoms, and the physician initially recommended a nebulizer treatment before later directing transfer to the ED. The resident was admitted to the hospital with bilateral pneumonia, acute hypoxic respiratory failure, likely demand ischemia, chronic diastolic CHF, fluid overload, severe anemia, and human metapneumovirus infection.
Physician Orders Did Not Match POLST Code Status
Penalty
Summary
The facility failed to ensure that active physician orders reflected residents’ end-of-life wishes as documented on their Pennsylvania POLST forms for three residents. Facility policy stated that residents are presumed to consent to CPR unless there is documentation in the medical record showing a DNR order, and that all DNR orders must be rewritten by the attending physician for each admission or readmission. Review of the clinical records showed that Resident R14 had diagnoses including COPD, A-Fib, and anxiety, and had a POLST indicating DNR, but the current physician orders lacked evidence of code status. Resident R38 had diagnoses including dementia, hypothyroidism, and high blood pressure, and had a POLST indicating DNR; however, a physician order dated in the record indicated CPR, creating inconsistency between the POLST and the physician orders. Resident R50 had diagnoses including COPD, respiratory failure, and diabetes, and had a POLST indicating DNR, but current physician orders also lacked evidence of code status. During interviews, the DON confirmed that Resident R14’s record lacked active physician orders reflecting code status and that Resident R38’s physician orders and POLST were not consistent, and further confirmed that resident physician orders and POLST should match regardless of the POLST.
Advance Directive Not Available in Resident Record
Penalty
Summary
The facility failed to ensure a resident exercised the right to formulate an Advance Directive. Review of the State Operations Manual, record review, and staff interview showed that Resident #5 had an advanced directive documented on a Care Conference Review Comprehensive dated 4/3/26, but the document could not be located in the medical record. Resident #5 was admitted and later readmitted to the facility with diagnoses including dementia with agitation, stroke, and pulmonary embolism. On 6/26/26 at 9:48 AM, a request was made for a copy of Resident #5's advanced directive. Later that day at 11:19 AM, the CEO confirmed that Resident #5 did not have an advanced directive on file. The report states that this deficiency involved 1 of 5 residents whose records were reviewed.
Failure to Offer Advance Directive Opportunity
Penalty
Summary
The facility failed to ensure residents were offered the opportunity to create an advance directive for Resident #13, who was re-admitted with multiple diagnoses including hypertension, chronic kidney disease, and mild cognitive impairment. Record review on 6/24/26 showed that Resident #13 did not have an advance directive on file. On 6/25/26 at 2:43 PM, the Social Service Director stated there was no documentation that education was provided to Resident #13 and no attempts were made to obtain an advance directive.
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