Invalid DNRO Led to CPR Against Resident’s Stated DNR Wishes
Summary
The deficiency involves the facility’s failure to ensure a resident’s Do Not Resuscitate (DNR) wishes were honored due to an invalid Florida Do Not Resuscitate Order (DNRO) form being provided to Emergency Medical Services (EMS). The resident, an elderly male with a history of stroke, type 2 diabetes, heart failure, HIV, coronary artery disease, renal insufficiency, and non-Alzheimer’s dementia, was admitted with a documented DNR order in the electronic medical record (EMR). A hospital transfer form indicated he was alert but disoriented, required a surrogate for decision making, and was a DNR. The EMR contained a Florida DNRO form dated and signed only by the hospital physician, with no signatures from the resident or an authorized representative, and no power of attorney, health care surrogate, or proxy documents were scanned into the EMR. On the morning of the incident, a CNA found the resident unresponsive at approximately 5:45 AM and notified the assigned RN. The RN assessed the resident, was unable to obtain a blood pressure, pulse, or respirations, and left the room to verify the code status in the EMR, which confirmed the resident was a DNR. Despite this, the RN called EMS and documented that she could not obtain vital signs. She later stated she thought she saw the resident take small breaths and called EMS based on a prior company policy, but could not explain the discrepancy between her observation and her documentation that respirations were absent. When EMS arrived, the RN showed them the DNR order in the EMR, and EMS requested a physical copy of the Florida DNRO form. The RN was unable to locate a paper DNRO form and instead printed the scanned hospital DNRO onto goldenrod paper. EMS determined the form was invalid because it lacked the signature of the resident or his authorized representative and therefore initiated CPR. EMS performed three rounds of CPR before discontinuing efforts and pronouncing the resident deceased at 6:40 AM. Interviews with the resident’s daughter confirmed she was his health care proxy, that she had informed facility staff of his wish to be a DNR, and that she was later told EMS performed CPR because the Florida DNRO form had not been signed. The Social Services Director and facility leadership acknowledged that staff had recognized the hospital DNRO form was incomplete prior to the event but failed to ensure a valid, signed Florida DNRO form was obtained and available, resulting in EMS performing CPR contrary to the resident’s documented DNR status. The facility’s policies for CPR and documentation required adherence to residents’ advance directives and accurate, complete documentation in the medical record. Staff interviews and the facility’s internal investigation confirmed that although the DNR order was present in the EMR and the need for a surrogate and DNR status had been identified, the Florida DNRO form remained incomplete and unsigned by the resident or his proxy at the time of the emergency. During the emergency response, the absence of a valid DNRO form led EMS to determine that CPR must be initiated. This sequence of actions and inactions—failure to complete and validate the DNRO form, lack of proper documentation of the proxy’s authorization on the DNRO, and reliance on an invalid hospital DNRO—resulted in the resident receiving CPR against his stated wishes.
Removal Plan
- Initiated an internal investigation including resident record review and staff interviews; notified the Department of Children and Families, the Florida Agency for Health Care Administration, and local law enforcement; validated notification of the attending physician/medical director and the resident’s responsible party regarding the event.
- Conducted a 100% audit of all current residents’ code status and care plans; verified the presence of a valid Florida DNRO form for each applicable resident in the EMR.
- Conducted code blue drills across all shifts.
- Implemented Emergency Response Binders containing the Florida DNRO form for applicable residents, a facility Florida DNRO verification checklist, and a code status reference guide for staff; placed binders at each nurses’ station, the rehabilitation department, and the social services office.
- Provided education to licensed nurses, the Social Services Director, and the Admissions Coordinator on the location of goldenrod (yellow) paper for printing Florida DNRO forms.
- Educated staff that CPR must be initiated by EMS unless a valid Florida DNRO form is physically available.
- Established designated locations for goldenrod (yellow) paper for Florida DNRO forms to prevent delays.
- Held an Ad Hoc QAPI committee meeting to review education and audits.
- Completed a 100% chart audit of advance directives including code status, DNR orders, and Florida DNRO forms.
- Educated all licensed nurses on Resident Rights regarding Advance Directives; verification of code status and advance directives; DNR orders; Florida DNRO forms and requirements; CPR policy and EMS response requirements; communication of code status; location of goldenrod (yellow) paper for printing Florida DNRO forms; and complete and accurate documentation in the EMR; administered a post-test to ensure understanding.
- Trained all licensed nurses and had them complete post-tests; continued education to include new employees.
- Conducted Code Blue Drills with licensed nurses; scheduled remaining staff to complete a code blue drill upon return from leave.
- Held Ad Hoc QAPI meetings and a Monthly QAPI meeting with Administrator, Director of Nursing, Medical Director, and administrative staff to review and revise education, audits, code blue drills, and post-tests as indicated.
- Conducted staff interviews across all shifts to validate knowledge of advance directives, code status verification, Florida DNRO form completion, and location of Emergency Response Binders; validated education, audits, and code blue drill participation through interviews and review of attendance sheets and post-tests.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with intact cognition, multiple medical diagnoses, and documented full code status was found unresponsive, pulseless, and nonbreathing while receiving care. An RN believed Hospice enrollment changed the code status to DNR and did not start CPR or call a code blue, despite the resident’s full code order being documented in the chart.
A resident with respiratory failure and COPD, whose advance directives and orders indicated Full Code, was found unresponsive by an RN. The RN checked for a pulse, confirmed the resident was gone, but did not start CPR or call EMS; another nurse also assessed the resident, and the resident was pronounced dead shortly after. Family members and the DON stated CPR was not initiated despite the resident’s Full Code status.
A resident with a documented DNRCCA order had CPR started during a respiratory emergency before the code status was verified, despite staff records showing the resident was DNRCCA and cognitively impaired. Staff reports described confusion during the event, with CPR initiated while family members were present and code status confirmation occurring after compressions had already begun. In a separate record review, another resident’s chart showed DNRCCA in the EMR and care plan, but the hard chart lacked signed code status documentation.
Ambu Bag Not Readily Available During Code Blue: A Full Code resident was found unresponsive and not breathing, and staff began CPR during a Code Blue, but an ambu bag was not readily available at the start of the event. Staff used a non-rebreather mask while looking for the ambu bag, and interviews confirmed the device was not in use when the code began. The DON stated an ambu bag is part of the expected emergency equipment and that a non-rebreather mask does not replace it.
A resident with full code status became unresponsive and staff began chest compressions, but an LPN did not immediately call 911 and CPR was performed without ventilations or rescue breathing. EMS arrived to find staff doing compressions only and documented that the resident had been without ventilations for more than 12 minutes before EMS initiated BVM ventilations and continued resuscitation efforts.
RN 2 did not maintain CPR/BLS certification from a provider that included the required hands-on skills component. File review showed the certification came from an online provider, and RN 2 stated the course was entirely online with reading, videos, and questions only, with no CPR skills demonstration. The DSD confirmed the certification needed hands-on validation under the facility CPR policy.
Failure to Provide CPR for Full Code Resident
Penalty
Summary
Facility staff failed to provide basic life support, including CPR, for a resident who was found pulseless and nonbreathing. The resident had diagnoses including peritoneal abscess, type 2 diabetes, and severe protein-calorie malnutrition, and a quarterly MDS assessment indicated a BIMS score of 13 out of 15, showing intact cognition. The resident was their own decision maker and had a documented full code status signed and dated in the medical record. The resident was enrolled in Hospice services, and on the night of the incident, CNA-G and CNA-H were providing a bed bath while RN-E entered the room to complete a skin check and change a dressing on the resident’s buttocks. After the dressing change, the resident began having loose stools. RN-E left to get additional wound supplies while the CNAs continued care, and CNA-H thought the resident had passed away and left to notify RN-E. RN-E returned, found the resident unresponsive without observable respirations or signs of life, and believed the code status had changed to DNR when Hospice services began. RN-E did not initiate CPR or call a code blue, and instead asked LPN-F to inform Hospice of the resident’s passing. The investigation found that the resident’s code status was accurately documented in the medical record, physician orders, and care plan, and that RN-E was aware the resident was full code but failed to follow the resident’s documented wishes and the facility’s emergency response procedures.
Failure to Initiate CPR and Call EMS for Full Code Resident
Penalty
Summary
The facility failed to initiate CPR and call EMS for a resident who was found unresponsive and had Full Code status. The resident had been admitted from an acute care hospital and had diagnoses including acute and chronic respiratory failure with hypoxia and hypercapnia, as well as COPD. Advance directives, the order summary, and the MAR/TAR all identified the resident as Full Code, and a progress note documented that the resident wanted to remain Full Code. According to the record and staff interviews, the resident was last seen at about 4:45 AM when a breathing treatment was started. At about 5:50 AM, an RN entered the room to tell the resident the shift was ending, found no response, touched the resident, and checked for a radial pulse, which was absent. The RN then went to the hallway and alerted the incoming nurse that the resident was gone. The RN later checked the chart and confirmed Full Code status, but CPR was not started and EMS was not called. Another nurse was present and also assessed the resident, with absent apical pulse confirmed, and the resident was pronounced dead at 6:00 AM. Family members stated they were told the RN panicked and did not start CPR or call EMS. The DON confirmed that the resident was Full Code and that the RN who found the resident unresponsive did not initiate CPR or check code status right away. The facility policy stated that when a resident is found without heartbeat and respirations, the nurse on duty identifies code status and, if the resident is Full Code, CPR is started and 911 is activated.
Advance directives not honored during CPR event and code status documentation incomplete
Penalty
Summary
The facility failed to honor advance directives for a resident with a documented DNRCCA order when CPR was initiated during a respiratory emergency. Resident #91 was admitted with acute respiratory failure with hypoxia, pulmonary embolism, and tracheostomy status, and the record showed the resident was cognitively impaired, totally dependent for ADLs, and had a physician order and care plan identifying DNRCCA status. During the event, staff were alerted that the resident was having trouble breathing, and the respiratory therapist entered the room, found the resident not breathing, and began CPR before the code status was verified. According to the facility investigation and staff statements, multiple staff members responded to the room, the crash cart was brought in, and CPR continued while EMS was called. One witness stated the family was asked if they wanted life support and said yes, while another witness stated the resident’s spouse and son were present and that the spouse was removed from the room. The regional nurse confirmed CPR was initiated when it should not have been because the resident had a DNRCCA order. The DON stated staff believed someone was sent to verify the code status while the code continued, and the respiratory therapist stated she did not have time to look in the chart before starting compressions. The facility also failed to ensure advance directive documentation was accurate in the medical record for another resident. Resident #28 had physician orders and a care plan indicating DNRCCA, but the record did not contain signed documentation verifying that status in the hard chart. A review of the electronic chart showed DNRCCA, while the regional nurse stated there was no signed code status paper in the medical record and reported that the resident had said he wanted to be a full code. The facility policy required advance directives to be maintained in the medical record and readily retrievable, and to be followed.
Ambu Bag Not Readily Available During Code Blue
Penalty
Summary
The facility failed to ensure the immediate availability of essential emergency resuscitation equipment for a resident who was designated Full Code during a Code Blue event. When the resident was found unresponsive and not breathing, staff initiated CPR, but an ambu bag was not readily available at the start of the emergency. Staff instead used a non-rebreather mask, and one nurse asked for an ambu bag to be brought from another floor. The resident’s code was documented as having been initiated immediately, with CPR continuing until EMS arrived and took over. Interviews confirmed that staff observed the ambu bag was not in use and was not readily available when the code began. A nurse stated that chest compressions were being performed when he arrived, but there was no ambu bag in use. Another nurse said staff were looking for the ambu bag and that it was not readily available at the start of the code, though one was brought in before EMS arrival. The DON stated that staff were expected to respond immediately with all necessary equipment, including an ambu bag, oxygen, and an IV starter kit, and acknowledged that a non-rebreather mask does not replace an ambu bag. The crash cart stock list identified one ambu bag on top of the cart, and the facility’s CPR policy stated that emergency basic life support should be provided immediately, including CPR, in accordance with physician orders and advance directives.
Failure to Provide Ventilations During Code Response
Penalty
Summary
The facility failed to provide basic life support to a resident with full code status when the resident became unresponsive and was found without vital signs. The resident had Huntington's disease, dysphagia, anxiety, gastrostomy status, severe cognitive impairment, and was dependent on staff for all activities of daily living. The care plan and physician orders reflected full code status, with CPR to be initiated in the event of a cardiac or respiratory event. On the evening of the event, staff identified the resident as unresponsive after dinner. LPN #200 checked the resident, found no vital signs, and began chest compressions after checking code status and bringing the crash cart to the room. However, staff did not immediately call 911; the call was made only after compressions had already started. EMS records showed the 911 call was received at 8:06 P.M. and EMS arrived at 8:18 P.M. When EMS arrived, staff were performing chest compressions without ventilations. EMS documented that the resident had been without ventilations for greater than 12 minutes and then initiated ventilations with a bag valve mask while continuing resuscitation efforts. Interviews and record review showed that LPN #200 and LPN #216 performed chest compressions only and did not provide rescue breathing or ventilations during the code. LPN #200 stated the bag valve mask was not used because staff did not know how to use it and believed it was not on the crash cart, although the cart audit logs and observation showed bag valve masks and CPR mouth shields were present. The DON stated that if a code occurred, staff should call 911, apply the AED, and have one nurse provide ventilations while another performed compressions. EMS later pronounced the resident deceased after resuscitation efforts were stopped by physician direction.
RN lacked CPR certification with hands-on skills validation
Penalty
Summary
The facility failed to ensure that RN 2 maintained current CPR certification from a CPR provider whose training included a hands-on session in accordance with accepted national standards. During employee file review with the DSD, RN 2’s BLS certification was found to have been obtained from an online CPR provider, and the DSD stated she did not know whether the certification was entirely web based without the required in-person hands-on component. RN 2 later stated that the BLS course she completed was entirely online and consisted of reading materials, watching videos, and answering questions, with no hands-on component or requirement to demonstrate CPR skills. During a later interview, the DSD stated RN 2 needed to obtain BLS certification that included a hands-on component where skills are validated, and said this was necessary to ensure staff competency in performing CPR. Review of the facility’s CPR policy showed that staff were to maintain current CPR certifications through a provider whose training included a hands-on session in a physical or virtual instructor-led setting in accordance with accepted national standards, and that online knowledge components were acceptable only when in-person skills demonstration was also required.
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