Failure to Honor Resident’s Documented DNR Status During Code Blue Event
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s Out-of-Hospital Do Not Resuscitate (OOH DNR) order and documented DNR status when the resident was found unresponsive and staff initiated resuscitation. The resident was an older female with diagnoses including depression, anxiety disorder, ALS, and a tracheostomy, and had a BIMS score of 15, indicating she was cognitively intact. Her care plan, physician orders, and an OOH DNR form signed by the physician and two witnesses all documented that her code status was DNR. Despite this, when she was found unresponsive in her room, staff proceeded with CPR and other resuscitative measures after determining she had no pulse and had stopped breathing. According to interviews and record review, an agency CNA discovered the resident unresponsive and notified an LVN, who assessed the resident and noted she was pale but breathing, with a weak pulse. Another LVN entered, performed a sternal rub and other stimuli without response, while the first LVN rechecked pulses at multiple sites and then reported finding no pulse and that the resident had stopped breathing. At that point, a Code Blue was called. Respiratory therapy staff removed the breathing circuit from the tracheostomy, suctioned the airway, and began manual ventilation with an ambu bag. Another LVN began chest compressions. During this period, staff questioned whether the resident was a DNR or full code, and there was hesitation because the LVN leading the response was unsure of the resident’s code status. Staff reported that the crash cart binder, which they relied on to verify code status, was not up to date and contained DNR information for residents who were no longer in the facility. The LVN in charge stated she attempted to verify the resident’s status by checking the crash cart binder and then the electronic medical record, but resuscitation had already been initiated and continued while this verification was pending. EMS arrived and continued compressions, and a pulse was recovered before the LVN informed EMS that the resident was actually a DNR based on the documentation she eventually located. The resident’s responsible party later confirmed that a DNR had been completed at the hospital and again at the facility, and stated that the resident did not want CPR, including having her ribs cracked, and that the facility did not abide by the resident’s wishes. The facility did not have a specific policy for Out-of-Hospital DNRs, only a general resident rights policy stating that residents have the right to refuse treatment.
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