Failure to Honor DNR Advance Directives Resulting in CPR on Two Residents
Summary
The deficiency involves the facility’s failure to ensure that residents’ advance directives, specifically Do Not Resuscitate (DNR) orders, were implemented as requested, resulting in CPR being performed on two residents who had chosen not to receive it. Facility policy dated 1/17 states that basic life support, including CPR, will be provided when needed, subject to physician order and resident choice as indicated in advance directives, and that CPR is not to be initiated when a valid DNR order is in place. Surveyors determined that the facility did not follow through on obtaining and processing valid physician-signed DNR orders and did not consistently verify and honor residents’ code status before initiating CPR. One resident, R102, was admitted with dementia, anxiety, and cellulitis and had been deemed incapacitated at the hospital. A Power of Attorney for Health Care (POAHC) was activated, and upon admission the POAHC signed a CPR preference form indicating that R102 did not want CPR in the event of cardiopulmonary arrest. The form stated that the physician must provide an order to withhold CPR for inclusion in the medical record, based in part on the resident’s preferences. The POAHC later signed the State of Wisconsin Emergency Care DNR form, which is used to request a DNR bracelet and outlines that only the bracelet identifies DNR status to EMS responders. On the day of the event, nursing notes document that R102 became unresponsive after heavy breathing and a seizure; staff attempted to obtain vitals, applied oxygen, called 911, and started CPR. The ADON later reported that she checked the chart, saw a red cover indicating DNR status, and informed the floor nurse that the resident was DNR, but CPR continued and EMS arrived to find staff performing CPR. The paramedic report for R102 documents that staff stated they believed the resident was DNR but that there was no DNR identification such as a bracelet. Staff produced the State of Wisconsin DNR form, but it lacked a physician signature at that time, and other documents such as the POAHC and living will were also provided. Because the DNR form was not signed by a physician and there was no DNR bracelet, paramedics continued CPR, including mechanical CPR, intraosseous access, airway placement, and administration of epinephrine, until they received confirmation allowing them to stop. The State of Wisconsin DNR form for R102 was not signed by a physician until after the resident had received CPR and died. The DON later stated that if there is no legally signed DNR form by the physician, nurses are required to perform CPR, and surveyors identified that the facility had not followed through in obtaining the physician’s signature despite the resident’s documented wishes for no life-sustaining measures. A second resident, R24, had diagnoses of lung and breast cancer and was cognitively intact per a BIMS assessment. R24 completed a CPR preference form indicating that CPR was not wanted in the event of cardiac arrest, and an Advance Directive for Emergency Care DNR form was signed by the resident’s physician. On the day of the incident, R24, who had a documented fish allergy, was served fish for lunch. During subsequent vital sign assessment, R24 became unresponsive, briefly recovered, then became unresponsive again. LPN-Y obtained an AED and started CPR, and 911 was called. The paramedic report states that EMS arrived to find staff performing CPR with mechanical ventilation and an AED in place. During resuscitation, staff presented a form showing the resident was DNR, and CPR was briefly stopped but then resumed because the document was viewed as only a request for a DNR bracelet and staff stated the resident was not wearing a DNR bracelet. The paramedic report for R24 further documents that, after CPR and life-saving measures were resumed, EMS instructed crew to double-check for a DNR bracelet and one was found around the resident’s forearm under a jacket. At that point, CPR was ceased and the resident was pronounced. LPN-S, the supervisor on duty, reported that she did not know the resident’s code status prior to starting CPR and did not observe a DNR bracelet, and that she would normally look in the electronic or paper record for code status. The DON later stated she did not know why staff started CPR on R24. Surveyors noted that the facility’s own Facility Reported Incident investigation focused on the fish allergy issue and did not investigate the concern that R24 received CPR contrary to the documented no-CPR advance directive. The surveyors concluded that the facility failed to ensure that both residents’ advance directive wishes regarding no CPR were honored, resulting in a finding of Immediate Jeopardy affecting all residents.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Advance Directive Not Maintained in Resident Record: A resident with dementia, muscle weakness, and protein-calorie malnutrition had documentation indicating an advance directive was in the chart, but record review did not locate a living will or DPOA for health care. The CNO confirmed the record did not include an advance directive and the facility did not have a living will on file.
Incomplete Advance Directive Documentation: The facility failed to keep complete and accurate advance directive records for two residents. One resident's chart contained a representative-signed acknowledgement that did not specify the type of advance directive, and another resident's record had no signed acknowledgement showing that advance directives were discussed. The SSD stated she was responsible for the documentation and that one form was filled out incorrectly while the other resident's paperwork could not be found.
The facility failed to timely respond to changes in condition for two residents, including one with severe cognitive impairment and another with dementia, CHF, diabetes, and a history of UTIs. Family members and DPOAs reported concerns about confusion, agitation, pain, SOB, and other worsening symptoms, but hospital evaluation was delayed while staff waited for physician input. Both residents were later admitted to the hospital with serious infections and other acute conditions, including sepsis, pneumonia, and respiratory failure.
A facility failed to ensure that active physician orders matched residents’ POLST code status for three residents. One resident with COPD, A-Fib, and anxiety had a POLST indicating DNR but no active code status order; another resident with dementia, hypothyroidism, and HTN had a POLST indicating DNR but a physician order for CPR; and a third resident with COPD, respiratory failure, and diabetes had a POLST indicating DNR but no active code status order. The DON confirmed the records were inconsistent and that physician orders and POLST should match.
A resident with dementia with agitation, stroke, and PE had an advanced directive noted in a care conference review, but the document could not be found in the medical record. Staff later confirmed the resident did not have an advance directive on file.
Failure to offer a resident the opportunity to create an advance directive. Record review showed the resident had no advance directive on file, and the SS Director stated there was no documentation that education was provided or that any attempts were made to obtain one. The resident had HTN, CKD, and mild cognitive impairment.
Advance Directive Not Maintained in Resident Record
Penalty
Summary
The facility failed to ensure that a copy of a resident's advance directive was maintained in the medical record for Resident #32, who was admitted with multiple diagnoses including dementia, muscle weakness, and protein-calorie malnutrition. The resident's care plan, revised 5/12/22, documented that the resident and appointed healthcare representative were to receive education regarding advance directives as needed, and a care conference evaluation dated 6/26/26 documented that the resident had an advance directive in the record. However, on 7/8/26, review of the medical record did not locate a living will or durable power of attorney for health care, and the CNO later confirmed that the record did not include an advance directive and the facility did not have a living will on file.
Incomplete Advance Directive Documentation
Penalty
Summary
The facility failed to ensure documentation regarding advance directives was complete and accurate for 2 of 7 residents reviewed. A policy titled "Advance Directives and Refusal of Treatment" stated that upon admission the Social Services Designee should obtain a copy of any existing Living Will, Health Care Proxy, Durable Power of Attorney for Health Care Decisions, or other recorded declaration and enter a progress note regarding the existence of an advance directive. Resident #7 was admitted with diagnoses including hemiplegia and hemiparesis following a nontraumatic intracerebral hemorrhage affecting the right dominant side. The record contained a "Resident Rights & Advance Directive Acknowledgement" signed by the resident's representative that indicated the resident had an advance directive, but the form did not identify the type of advance directive. Resident #81 was admitted with end stage renal disease, and the medical record contained no signed acknowledgement showing that advance directives were discussed with the resident or representative. The Social Services Director stated she was responsible for advance directive documentation, that the form for Resident #7 was filled out incorrectly and should have been corrected, and that the missing paperwork for Resident #81 meant the facility would not know whether the resident had an advance directive.
Delayed Response to Changes in Condition and Family Requests for Hospital Evaluation
Penalty
Summary
The facility failed to timely provide requested medical evaluation and treatment for two residents with changes in condition. The deficiency was identified during review of Complaint #3035494 and involved delayed responses to worsening symptoms, resulting in delayed medical treatment, worsening of condition, and dissatisfaction with care. For one resident with diagnoses including Alzheimer's disease and other medically complex conditions, the record showed severely impaired cognition and inability to make decisions. A family member reported that the resident had a decline in health about a week before hospitalization, with severe UTI and stool impaction. The hospital record documented that the resident arrived from the nursing home via EMS with confusion and altered mental status that had worsened since several days earlier, and the ED physician suspected sepsis. The resident was febrile, tachycardic, had elevated white blood cell count and creatinine, and was diagnosed with proctitis, cystitis, sepsis, NSTEMI, and acute kidney injury. The urine culture was positive for gram-negative rods/Pseudomonas aeruginosa. For another resident with diagnoses including diabetes mellitus, a history of UTIs, CHF, Alzheimer's disease, and dementia, the progress notes showed family concerns about abnormal behavior, confusion, agitation, shortness of breath, congestion, lethargy, and shallow breathing. The resident's DPOA reported repeatedly expressing concern that something was wrong and requesting hospital evaluation, but the facility did not immediately send the resident out and instead contacted the physician first. The change-in-condition documentation noted altered mental status and respiratory symptoms, and the physician initially recommended a nebulizer treatment before later directing transfer to the ED. The resident was admitted to the hospital with bilateral pneumonia, acute hypoxic respiratory failure, likely demand ischemia, chronic diastolic CHF, fluid overload, severe anemia, and human metapneumovirus infection.
Physician Orders Did Not Match POLST Code Status
Penalty
Summary
The facility failed to ensure that active physician orders reflected residents’ end-of-life wishes as documented on their Pennsylvania POLST forms for three residents. Facility policy stated that residents are presumed to consent to CPR unless there is documentation in the medical record showing a DNR order, and that all DNR orders must be rewritten by the attending physician for each admission or readmission. Review of the clinical records showed that Resident R14 had diagnoses including COPD, A-Fib, and anxiety, and had a POLST indicating DNR, but the current physician orders lacked evidence of code status. Resident R38 had diagnoses including dementia, hypothyroidism, and high blood pressure, and had a POLST indicating DNR; however, a physician order dated in the record indicated CPR, creating inconsistency between the POLST and the physician orders. Resident R50 had diagnoses including COPD, respiratory failure, and diabetes, and had a POLST indicating DNR, but current physician orders also lacked evidence of code status. During interviews, the DON confirmed that Resident R14’s record lacked active physician orders reflecting code status and that Resident R38’s physician orders and POLST were not consistent, and further confirmed that resident physician orders and POLST should match regardless of the POLST.
Advance Directive Not Available in Resident Record
Penalty
Summary
The facility failed to ensure a resident exercised the right to formulate an Advance Directive. Review of the State Operations Manual, record review, and staff interview showed that Resident #5 had an advanced directive documented on a Care Conference Review Comprehensive dated 4/3/26, but the document could not be located in the medical record. Resident #5 was admitted and later readmitted to the facility with diagnoses including dementia with agitation, stroke, and pulmonary embolism. On 6/26/26 at 9:48 AM, a request was made for a copy of Resident #5's advanced directive. Later that day at 11:19 AM, the CEO confirmed that Resident #5 did not have an advanced directive on file. The report states that this deficiency involved 1 of 5 residents whose records were reviewed.
Failure to Offer Advance Directive Opportunity
Penalty
Summary
The facility failed to ensure residents were offered the opportunity to create an advance directive for Resident #13, who was re-admitted with multiple diagnoses including hypertension, chronic kidney disease, and mild cognitive impairment. Record review on 6/24/26 showed that Resident #13 did not have an advance directive on file. On 6/25/26 at 2:43 PM, the Social Service Director stated there was no documentation that education was provided to Resident #13 and no attempts were made to obtain an advance directive.
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