On July 26, 2019, BrandyWyne Health Care Center in Winter Haven was cited for failing to protect the rights of a resident by violating her end-of-life wishes. When found unresponsive, the nursing staff attempted to revive her because they didn’t know for sure if she was DNR (Do Not Resuscitate). They did not honor her request to have a peaceful and dignified death, and they failed to protect her from unwanted interventions during her last moments of life.
Resident’s End-of-Life Wishes
The resident had signed a DNR order, which was also signed by her Durable Power of Attorney (DPOA) and a physician. Despite this, the facility called emergency services and provided unwanted treatments of cardiac compressions and artificial ventilation to prolong her life.
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Breakdown in Procedure
A progress note from a Licensed Practical Nurse (LPN) revealed that they went in to do Resident #3’s morning medication and noticed she was unresponsive. The LPN called for another nurse to call code blue and 911. The EMTs arrived and took over with compressions. Further review of progress notes for Resident #3 revealed the LPN had told a new Registered Nurse
(RN) that she thought the resident had a DNR. However, clinical records at the resident’s previous facilities had indicated she wanted to pass peacefully. When the CPR failed to work and the resident passed, a physician called for an order to release the body. The family was then notified that their loved one passed, and the family informed the facility they would be calling for more information.
The LPN looked up the codes status on the running sheet she had on her medication cart, and the running sheet did indicate the DNR order. She explained the running sheet was a sheet they used to indicate all code statuses for the residents. The LPN said that if the resident had a room change, they might just cross out the name and may not change the other information on the sheet. When the LPN looked in the computer at the code status, it indicated a full code (the resident should be resuscitated). This shows inconsistencies in how the code statuses were handled. The facility didn’t have a clear procedure for updating information that existed in multiple places, thereby causing confusing about the resident’s end-of-life wishes.
Post-Event Communication
The LPN also said that after CPR, she called the Unit Manager to tell her that Resident #3 had passed. She told her there was confusion with the code status because she remembered getting a report that the resident had a DNR, but full code was in the computer system. She stated they had already started CPR, so they had to finish it. When EMS arrived, they took over for them. The LPN stated she went out to the nursing station and got the paperwork together. The EMT came out and told her the resident had passed. According to another LPN, no one was writing anything down during the code because she and others were doing the CPR with a crash cart and a back board.
The police were at the facility first when 911 was called, and they asked the LPN if there was confusion over the resident’s code status. She said, “to me, it was.” She stated there were two charts in the computer. The first chart had nothing in the record, just the resident’s name. So, she scrolled down and the nurse assessment coordinator came to help her. She told the coordinator that she could not see the code status in the computer at all. The coordinator left the floor and came back with the paper, stating that she was a DNR. The LPN said there was nothing in the yellow book (used to hold resident DNR forms for that unit) for this resident. She didn’t know where the Coordinator pulled the form from. She stated she didn’t know how they knew she was full code and “freaked out” because there was no information in the record.
Family’s Perspective
When speaking with the resident’s daughter, she confirmed her mom’s wishes were to go peacefully. The daughter initially believed that her mom’s end-of-life wishes were actually honored. She stated the nurse who called with the news told her she went into her Mom’s room that morning, and she was gone. The daughter said she wasn’t asked about her mom’s code status on the day she passed, nor was she informed her mom had received CPR. The nursing facility was not forthcoming about the circumstances of her mom’s death. Not only did they violate her mom’s wishes, but they apparently were deceitful in telling her daughter what happened.
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Importance of Respecting End-of-Life Wishes
Why no one checked to verify the status of the resident’s DNR order is unclear. When you place your loved one in a nursing home, you need the staff and administrators to know and comply with your loved one’s wishes. With something as important as an end-of-life request, you expect them to get it right. When nursing homes don’t know or respect your loved one’s wishes, they betray the trust you placed in them to care for your loved one. If the nursing home had known for sure that the resident didn’t want to be revived, she would have passed peacefully.
This facility appears to have lied to the resident’s daughter about how she passed, and they grossly failed to protect the end-of-life wishes for a resident. Because of that, she was exposed to unnecessary CPR and life-saving procedures. She didn’t get the only thing she wanted at the end of her life, which was to pass away in peace.
If you suspect nursing home abuse, we will provide a free, confidential case evaluation with no obligation to hire us. We treat our clients with compassion and aggressively represent their rights, making nursing homes take responsibility for abuse. Distasio Law Firm has the expertise and ability to advocate for victims of nursing home abuse and neglect, even if a case goes to trial. Contact us today.
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