Failure to Honor DNR Order and Report Adverse Event to APS
Penalty
Summary
The deficiency involves the facility’s failure to report an adverse event that violated a resident’s rights when CPR was performed despite an active Do Not Resuscitate (DNR) order. Record review showed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 on a recent MDS, indicating the resident was cognitively intact. The physician order report documented a current DNR order, a legally binding medical document instructing that CPR not be performed if the resident’s heart or respirations ceased. On the date of the incident, nursing progress notes documented that the resident was found unresponsive and without a pulse, and CPR was initiated. Facility documentation of the Code Blue event showed that the resident became unresponsive in the dining room and CPR was started. During the resuscitation, staff noted the resident’s DNR status but continued CPR, and the resident was later transferred to acute care. A review of the facility’s 2026 Reportable Events log revealed that this event, including the investigation, was not reported to Adult Protective Services (APS). In interviews, the Administrator confirmed that CPR was initiated despite the resident’s DNR status and that the event was not reported to APS, and the resident confirmed that CPR had been performed against physician orders and personal wishes, while stating they remained DNR and would not want CPR again.
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