Failure to Communicate and Update Resident DNR Status Resulting in CPR Contrary to Wishes
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s code status preference was clearly and accurately reflected in the medical record and available to staff, resulting in CPR being initiated contrary to the resident’s documented wishes. The resident was admitted with diagnoses including atrial fibrillation, cardiac disease, stroke, and lung disease, and was initially listed as a full code in the facility’s electronic medical record and on the face sheet. The facility’s practice was to default all new admissions to full code status until staff could confirm the resident’s preferences. The resident had normal cognition on the admission MDS and later completed an Outside Hospital Do-Not-Resuscitate (OHDNR) order, which was signed and dated by both the resident and the physician. The sequence of events leading to the deficiency began when the Admissions Director completed the admission paperwork with the resident, including code status and DNR documentation, and then placed all forms in a folder on their desk before leaving for the weekend. The Admissions Director did not notify nursing staff that the resident’s code status had changed from full code to DNR, did not make copies for the nursing charts, and did not provide the DNR paperwork to the Social Services Director (SSD) or the Director of Nursing (DON). As a result, the SSD created the resident’s electronic profile as a full code and did not receive or review the signed DNR form until after the resident’s death. The DON reported not receiving any DNR paperwork prior to the resident’s cardiopulmonary arrest, and the resident’s orders were not updated in the hard chart, EMR, or on the red/green door sticker system used to indicate code status. When the resident was later found unresponsive, staff followed the information available to them, which indicated the resident was a full code. Staff immediately called the nurse, initiated CPR, and called 911. EMS arrived and continued CPR for over an hour. During this time, the DON was called to the facility and contacted the family while the code was in progress. The resident’s progress notes documented the discovery of the resident unresponsive, the initiation of CPR, EMS involvement, and subsequent notifications to the family and physician. Only after these events did the SSD, while scanning the admission packet into the EMR, discover the signed DNR order that had not been communicated or entered into the resident’s record, confirming that staff had provided CPR despite the resident’s documented DNR preference.
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