F0578

D

Failure to Honor Resident DNR Due to Inaccurate Code Status in EMR

Freeport, Illinois Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The facility failed to honor a resident’s advance directive by allowing resuscitation efforts to occur despite documented Do Not Resuscitate (DNR) orders. The resident had diagnoses including COVID-19, rib contusion, chronic kidney disease, depression, and venous insufficiency. The physician’s orders specified DNR, and a POLST form indicated “No CPR: Do not attempt resuscitation.” However, the electronic medical record banner listed the resident as “Full Code,” and the POLST form was not scanned into the electronic record until a later date. The facility’s policy required that advance directives be documented in the medical record and specified on the face sheet, and that all advance directives be uploaded into the medical record system and stored in the clinical record.

When EMS arrived in response to the resident’s fall, they found the resident prone on the floor, breathing and moaning in pain. A staff member standing next to the resident informed EMS that the resident was a full code, and EMS initiated full resuscitative measures after the resident became pulseless, including manual chest compressions, BVM ventilation with oxygen, IO access, multiple doses of epinephrine, and use of a mechanical CPR device. CPR was continued until arrival at the hospital, where it was discontinued after hospital staff produced a valid DNR on file. The RN later stated she told EMS the resident was a full code because that was what the chart banner showed, and that she relied on the banner as the source of code status. The DON and wound care nurse stated that everyone is treated as full code until paperwork is received and that the admitting nurse would not have entered a DNR order without seeing the POLST, indicating the facility had the POLST but had not updated the banner to DNR, leading to confusion about the resident’s code status.