An Atlanta Journal-Constitution (AJC) analysis identified more than 100 Georgia Department of Community Health (DCH) investigations where do-not-resuscitate (DNR) paperwork or practices were not properly followed in nursing homes, assisted living facilities, and personal care homes in the past five years. In some cases, staff failed to administer CPR and residents died, even though their medical record indicated they wanted to be resuscitated. According to the AJC review, facility employees often had trouble completing, filing, or identifying resident DNRs.
The AJC analysis found that even with written directives, resident wishes weren’t always followed. In one case, two residents at a facility died after staff mistakenly thought they had DNRs.
Resident 1 had been found in bed, unresponsive, with no vital signs. Their Advance Directive status was initially inaccurately assessed by licensed nursing staff as DNR in the electronic record, so no emergency basic life support was immediately provided. The physician and the director of health Services (DHS) were notified. Approximately one hour later, while documenting the incident in the resident’s clinical record, staff discovered that the resident had a full code status rather than a DNR status. CPR was initiated and Emergency Medical Services (EMS) were notified. EMS arrived and continued to provide additional emergency support. However, basic life support measures were not successful, and the resident was pronounced dead.
Resident 2 was found in bed, unresponsive to all stimuli and without vital signs. The resident’s Advance Directive status was listed in the electronic clinical record as DNR, so licensed nursing staff did not provide emergency basic life support measures and the resident was pronounced dead. However, the DNR status in the clinical record was inaccurate. There was no supporting physician’s order or signed DNR documentation to support the DNR status listed in the resident’s clinical record.
In another case, an assisted living facility resident wanted a DNR. According to state records, facility staff failed to have the resident sign the correct forms until over a year later, when the resident, who was diagnosed with dementia, was in failing health and unable to speak.
Another resident, with the mental capacity of a 10-year-old, signed a DNR at her facility, without her caretaker brother being informed. That facility used photocopied forms with preexisting physician signatures instead of having each resident’s situation evaluated by a physician.
Issue:
Facility staff should verify the presence of Advance Directives or the resident’s wishes with regard to CPR upon admission. This may be done while completing the admission assessment. If the resident’s wishes are different than the admission orders, or if the admission orders do not address the resident’s code status and the resident does not want to receive CPR, facility staff should immediately document the resident’s wishes in the medical record and contact the physician to obtain the order, complete the required documentation, and obtain signatures. While awaiting the physician’s order to withhold CPR, facility staff should immediately document discussions with the resident or resident representative, including, as appropriate, a resident’s wish to refuse CPR. At a minimum, a verbal declination of CPR by a resident, or if applicable a resident’s representative, should be witnessed by two staff members, though individual States may have more specific requirements related to documenting verbal directives. While the physician’s order is pending, staff should honor the documented verbal wishes of the resident or the resident’s representative, regarding CPR if state requirements allow. The presence of an Advance Directive does not absolve the facility from giving supportive and other pertinent care, including CPR and other basic life support that is not prohibited by the Advance Directive.
Discussion Points:
- Review your policies and procedures on Advance Directives, DNR, and accurate recordkeeping. Update as needed.
- Train licensed staff on your policies on CPR, DNR, and on accurate documentation and recordkeeping. Document that these trainings occurred, and file the signed documents in each employee’s education file.
- Periodically audit residents’ records to ensure DNR paperwork is correctly filled out and physician orders are included and properly signed. Also determine that all areas where CPR and DNR status are recorded are in agreement with the physician’s orders. Review the resident’s CPR/DNR status minimally with each MDS quarterly and comprehensive assessment. If your state requires the use of a MOLST or POLST, maintain this document in a readily accessible location.
