F0678

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Invalid DNRO Led to CPR Against Resident’s Stated DNR Wishes

Ocoee, Florida Survey Completed on 03-05-2026

Penalty

No penalty information released

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.