Failure to Honor DNR Order and Resident Rights
Summary
The facility failed to honor a resident's documented Do Not Resuscitate (DNR) order as indicated in the Physician Orders for Life-Sustaining Treatment (POLST) and other medical records. When the resident was found not breathing, multiple nursing staff, including RNs and LVNs, initiated and continued cardiopulmonary resuscitation (CPR) for seven minutes without verifying the resident's code status. The decision to start CPR was based solely on an unidentified person shouting that the resident was a full code, rather than checking the resident's POLST, Admission Record, or electronic health record, all of which clearly indicated a DNR order. The involved staff, including those who performed CPR and those who assisted, admitted during interviews that they did not check the resident's code status and instead relied on the verbal assertion from an unidentified individual. The resident's POLST, Admission Record, and care plan all indicated DNR status, and the resident had previously expressed his wish for DNR due to his medical condition, including a cancer diagnosis. Despite these clear directives, the staff proceeded with resuscitation efforts until paramedics arrived and identified the DNR order in the resident's documentation. Facility policy and procedures required staff to verify code status and honor residents' rights to refuse life-sustaining treatment. However, these procedures were not followed during the emergency. The Director of Nursing and other staff acknowledged that the resident's wishes were not respected and that the failure to verify code status before initiating CPR was a violation of both facility policy and the resident's rights.
Removal Plan
- The Social Services Director (SSD), the DON, and the Assistant DON (ADON) conducted an in-house audit of each resident's POLST, Advance Directive, and History & Physical (H&P) exam to determine if the resident had the capacity to make decisions and to verify the resident's responsible party if the resident did not have the capacity to make decisions.
- The Interdisciplinary Team (IDT) reviewed the medical record of all residents and verified which residents were Full Code, which were DNR, and which had advanced directives.
- RNC 2 provided reinforcement training to LVN 1, RN 1, RN 2, and RNC 1 on Resident Rights, POLST, Communication of Code Status, CPR, DNR, Advance Directive, and Medical Emergency Response.
- The SSD and the DON met with residents who had the capacity to make their own decisions and verified that their POLST was current.
- The SSD and the DON spoke with the resident representative of each resident who did not have the capacity to make decisions, to verify if their POLST is current. All the resident representatives stated that the POLST is current and there are no changes.
- The Medical Records Director (MRD) printed current Admission Record (face sheets) of each resident reflecting the verified POLST.
- The ADON printed out the list of all residents with their Code Status Orders Report (based on the POLST) and visibly posted the list at each nurses' stations, emergency cart, and in a binder at the medication carts. The Code Status Order Report will be updated daily by the 11pm to 7am licensed nurses and checked for accuracy. The 7am to 3pm licensed nurses will update any report not completed during the prior 11pm to 7am shift.
- The DON placed DNR stickers on the outside of the confirmed DNR residents' medical records to clearly display their DNR status. The 11pm to 7am licensed nurses were tasked to reconcile the Code Status Order Report daily with the DNR stickers and update as necessary. The MRD will audit the DNR stickers on the medical records and reconcile it with the Code Status Order Report weekly to ensure accuracy. The audit will be documented utilizing a Code Status audit form. Any inaccurate findings will be immediately corrected by MRD. The Code Status audit form will be available in the facility's binder with all documents related to the IJ Situation (IJ Binder).
- The licensed nurse assigned to the desk work will discuss resident code status during huddle for all three shifts. During the huddle the nursing supervisor will assign a licensed nurse as the Shift Code Leader should any incident occur.
- The SSD placed red wristbands (to visually identify DNR status) on the wrists of residents with DNR orders with their consent. Residents with DNR status agreed to wear the red wristbands. The IDT updated the Care Plans of the residents with DNR orders. All licensed nurses are tasked to print the code status report and visually verify that red wristbands are worn by the residents with orders for DNR and document it on the DNR Form list. The MRD will audit residents' care plans weekly utilizing the Code Status audit form to ensure compliance and accuracy.
- The ADM updated the Person-Centered Interview and Rounding Worksheet to reflect the wristband section for department managers to visually verify that the wristband is intact on their assigned residents on Monday through Friday basis. Registered Nurse (RN) supervisor will conduct the audit on weekends utilizing Weekend Room Round form. Department Managers and RN supervisor will utilize the Code Status Order Report to ensure accuracy during rounds. The Person-Centered Interview and Rounding Worksheet and Weekend Room Round forms will be available the Room Rounds binder.
- A mandatory facility-wide in-service training was conducted to reinforce the facility's P&P including Resident Rights, POLST, Communication of Code Status, CPR, DNR, Advance Directive, and Medical Emergency Response. 100% of the staff received the in-service training. New hires will be educated prior to the start of their first scheduled shift.
- The ADM or the DON will interview employees from different shifts on weekly basis to validate understanding of the in-service training on Resident Rights, POLST, Communication of Code Status, CPR, DNR, Advance Directive, and Medical Emergency Response. Employee response will be recorded utilizing an Employee Validation form. The form will be available in the IJ Binder.
- Regular audits during IDT meetings will include verification of the residents' clinical record for the current code status. Newly admitted residents' code status will be reviewed during IDT meetings. The audit will be done upon admission and readmission of residents, weekly for current residents or when where there is a change in residents' code status. The audits will be documented utilizing the Code Status audit form and will be reported by the MRD during Monday through Friday operations meeting for appropriate follow up.
- The IDT conducted Root Cause Analysis (RCA) and identified the following: a. Code status was not immediately visible during an emergency requiring life-saving measures if appropriate. b. There was a lack of visual cues such as DNR sticker or resident identifier such as red wristbands.
- A QAPI (Quality Assurance & Performance Improvement) was implemented to track and report on above audit findings. The findings will be presented at the monthly QA Committee meeting for a minimum of three months for review and recommendations. After the initial three months, the QA Committee will decide regarding the continued frequency of audits and subsequent reporting, with audits continuing at least monthly to sustain compliance.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to preserve dignity occurred when staff placed a brief on a cognitively intact resident who was continent of bowel and bladder. The resident stated the brief made him feel like a baby, and a NA confirmed she applied it even though he was not incontinent; RN and DON both verified the resident was continent and that briefs should not be placed on continent residents.
Failure to Knock Before Entering Rooms and Exposed Urinary Bag: A CNA entered three residents' rooms without knocking, and each resident said staff should knock and that they preferred privacy. The residents had diagnoses including encephalopathy, heart failure, respiratory failure, malnutrition, and sepsis, with moderate cognitive impairment documented for three of them. In addition, a resident with a urinary catheter was observed with an exposed urine bag hanging from the bed without a privacy cover, and the urine could be seen from the hallway; interviews confirmed privacy covers were required and that exposed urine affected dignity.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's dignity was not maintained during a blood sugar check when an RN performed the finger stick in the day room with two other residents and a visitor present and loudly announced the result. The RN did not ask permission before checking the resident's blood sugar in the common area, and the resident was described as alert, oriented, and new to the facility.
Cell Phone Use During Resident Care: CNAs were observed and reported using personal cell phones while providing care, including showers, in resident rooms, at nurses’ stations, in hallways, and while supervising smoking times. Nine confidential residents said the behavior made them feel ignored, embarrassed, and that their privacy was violated. The DON and ADM stated residents should receive privacy and full attention during care, and the facility policy required staff to treat residents with kindness, respect, dignity, privacy, and confidentiality.
Staff failed to maintain resident dignity during wheelchair transport and assisted feeding. A resident with dementia and severe cognitive impairment was transported in a geriatric wheelchair while facing backward, slumped over, and moaning as a CNA pulled the chair from the front, preventing the resident from seeing where he was going. Two cognitively impaired, fully dependent residents were assisted with eating by CNAs who stood over them rather than sitting at eye level, despite chairs being available in the room and dining area. One CNA reported not knowing she was expected to sit while feeding, and another stated she remained standing to monitor other residents who were self-feeding while she was the only staff member present.
Failure to Preserve Dignity by Placing a Brief on a Continent Resident
Penalty
Summary
The facility failed to provide services in a dignified manner for 1 resident who was cognitively intact and had diagnoses including renal insufficiency, DM, and hypertension. The resident’s MDS identified him as continent of bowel and bladder and needing staff assistance with ADLs including bed mobility, transfers, and toileting. A bowel and bladder assessment also identified the resident as continent, and the care plan stated he was aware of the need to void or defecate and would request to use the toilet as needed. During interview, the resident stated staff put diapers on him even though he was not incontinent and said it made him feel like a baby. During observation, a NA placed a brief on the resident, and the resident showed the surveyor the brief and stated it had just been put on him a few minutes earlier. The NA verified she placed a brief on the resident that morning even though he was not incontinent and said she was unsure why she did so. RN-A confirmed the resident was continent and stated staff put a brief on him out of habit. The DON stated staff should not place a brief on residents who are continent and that it was important to maintain the resident’s dignity.
Failure to Knock Before Entering Rooms and Exposed Urinary Bag
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity when CNA B did not knock before entering the rooms of Resident #20, Resident #59, and Resident #64. Resident #20 was a female with diagnoses including metabolic encephalopathy, hypertensive chronic kidney disease, hyperlipidemia, hypertension, weakness, and unsteadiness on feet, and her BIMS score was 08. Resident #59 was a female with diagnoses including heart failure, respiratory failure, muscle weakness, GERD without esophagitis, hypertension, and sepsis, and her BIMS score was 10. Resident #64 was a male with diagnoses including protein-calorie malnutrition, sepsis, hypertension, kidney failure, and alcohol abuse, and his BIMS score was 09. Each resident stated staff did not knock on the door and that they wanted staff to knock before entering their rooms. Observations during breakfast tray pass showed CNA B entering Resident #59's room at 7:17 a.m., Resident #64's room at 7:25 a.m., and Resident #20's room at 7:28 a.m. without knocking first. During interviews, Resident #59 said staff were supposed to knock and that staff would just walk in, including when she was being changed. Resident #64 said staff walked into his room all the time and that he got irritated when they did not knock. Resident #20 said staff never knocked on the door and that she preferred they knock, especially if the door was closed. The facility also failed to ensure Resident #102's urinary catheter had a privacy cover. Resident #102 was a female with diagnoses including hearing loss, pain, hypertension, cognitive communication deficit, and a rib fracture with pain, and her BIMS score was 99, indicating unable to complete the interview. Observations showed a urinary bag hanging from the side and bottom of her bed with no privacy cover, and the urine was visible from the hallway. Interviews with CNA B, MA F, CNA A, Central Supply, and the DON indicated privacy bags were supposed to be used for urinary bags and that exposed urine affected dignity and self-worth. The resident's care plan did not reflect anything about the catheter, and the report states the Dignity Policy required each resident to be cared for in a manner that promotes and enhances well-being, satisfaction with life, and feelings of self-worth and self-esteem.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Maintain Resident Dignity During Blood Sugar Check
Penalty
Summary
The facility failed to maintain a resident's dignity during a blood sugar check for Resident 97. During an observation on 5/1/26 at 11:21 a.m., RN 1 prepared to check the resident's blood sugar while the resident was sitting in her wheelchair in the day room with two other residents and a visitor present. RN 1 told the resident she was going to check her blood sugar, stuck the resident's finger, checked the blood sugar, and announced the result loudly in the common area. RN 1 did not ask the resident for permission to perform the blood sugar check in the common area with others present. During an interview later that day, Unit Manager 1 stated the resident was alert and oriented and new to the facility, and that they were working on a care plan indicating the resident was okay with having her blood sugar checked in common areas.
Cell Phone Use During Resident Care
Penalty
Summary
The facility failed to treat residents with respect, dignity, and care in a manner that promotes quality of life and recognizes each resident’s individuality for 9 confidential residents. The deficiency was based on resident interviews and record review showing that CNAs were using personal cell phones while providing care, including assisting with showers, performing care in resident rooms, and supervising residents during supervised smoking times. Residents stated staff texted and talked on their phones while walking in hallways, at nurses’ stations, and while performing care in their rooms, and they reported that this occurred on every shift and often in the facility. The residents also stated they did not know the names of the CNAs involved. The 9 confidential residents stated the cell phone use made them feel ignored, not a priority, embarrassed, and concerned that a CNA could make a mistake because of distraction. They also stated their privacy was violated. During interviews, the DON and ADM stated residents should receive privacy and full attention during care, and both stated staff were trained on privacy, resident rights, dignity, and cell phone usage. The record review included the facility policy titled Resident Rights, dated February 2021, which stated employees shall treat all residents with kindness, respect, and dignity and that residents have the right to a dignified existence, to be treated with respect, kindness, and dignity, and to privacy and confidentiality.
Failure to Maintain Resident Dignity During Transport and Assisted Feeding
Penalty
Summary
The deficiency involves failure to honor residents’ rights to dignity and respectful treatment during transport and meals. One resident with dementia, anxiety, severe cognitive impairment, and total dependence for ADLs was observed seated in a geriatric wheelchair, slumped over with his head hanging and eyes open, and moaning while a nurse aide pulled the chair down the hall from the front, causing the resident to face backward and be unable to see where he was going. The aide reported she pulled the chair because it was hard to push and acknowledged she had been educated on dignity and respect and should have pushed the resident in front of her, which would have allowed her to see his slumped posture and hear his moaning. The DON confirmed that the resident should have been pushed in front of the aide and that this was a dignity issue. The deficiency also includes failure to promote dignity during meals for two residents with severely impaired cognition who were dependent on staff for eating. One resident with a traumatic brain injury was observed in bed with the head of the bed elevated while an agency nurse aide stood over the bedside and assisted with eating without sitting at eye level, despite a chair being available in the room; the aide stated she had never heard of needing to sit to feed a resident and only sat after being questioned. The other cognitively impaired, fully dependent resident in a semi-reclined geriatric chair in the dining room was fed by the same nurse aide, who stood over the resident while feeding despite an empty chair being available; the aide later stated she believed she had no chair and also needed to stand to watch three other residents feeding themselves at another table while she was the only staff member present in the dining area. The DON stated she expected staff to sit when assisting residents during meals to promote dignity.
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