F0550

D

CPR Performed Despite Resident’s Active DNR Order

Lincoln, Nebraska Survey Completed on 03-11-2026

Penalty

No penalty information released

Summary

Facility staff failed to honor a resident’s right to self-determination and to follow physician orders by initiating cardiopulmonary resuscitation (CPR) on a resident who had a current Do Not Resuscitate (DNR) order. The resident’s Minimum Data Set dated 3/4/2026 showed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. A physician order report dated 2/11/2026 documented a DNR order for this resident. However, a nursing progress note dated 2/23/2026 at 9:47 AM recorded that the resident was found unresponsive and without a pulse, and CPR was initiated by facility staff. In an interview, the Administrator confirmed that CPR was started despite the resident’s DNR status and that CPR should not have been initiated due to the resident’s wishes. In a separate interview, the resident confirmed that CPR had been performed against physician orders and personal wishes, stated being happy to be alive, but affirmed not wanting CPR to be initiated again and remained a DNR.