Egret Cove Center Staff Perform CPR on Do-Not-Resuscitate Resident

Egret Cove Center in Saint Petersburg was cited for failing to protect a resident’s end-of-life wishes when staff members performed cardiopulmonary resuscitation (CPR) on a Do-Not-Resuscitate (DNR) resident. The facility failed to protect the resident’s rights, and she endured potentially violent interventions to prolong her life.

Before the incident occurred, the resident had a DNR order signed after she was transferred to the hospital due to an altered mental status. While at the hospital, the resident’s health significantly declined. Because of her poor health, she had a State of Florida DNR order form signed by her mother, who was her health care proxy. Her mother stated it was hard to see her daughter suffer for so long, and she supported the decision to reject life-saving interventions.

A review of the resident’s worksheet after the incident revealed that when a CNA found the resident unresponsive, they called for a Licensed Practical Nurse (LPN) to bring in the emergency cart to the resident’s room for CPR. A telephone interview with the LPN confirmed that she initiated CPR on the resident without checking her chart. The LPN said she had been a nurse for several years and “felt terrible” for not checking the code status of the resident before initiating CPR.

A staff member further confirmed that the resident had a full code status prior to her recent hospitalization. A full code status means that when a resident is unresponsive, staff members will call “Code Blue” and initiate CPR to revive the resident. “Code Blue” is often referred to as a “code” and is an emergency situation where staff members rush to begin CPR. The nurse said she thought the resident still had a full code status, even though the resident had indicated she was DNR a week before. Nursing home residents fully rely on the care of staff. When staff members do not verify information, they put the lives and well-being of residents at risk. In this case, a resident received unwanted interventions to prolong her life and was not granted her wish to pass peacefully.

Another interview with a staff member revealed that when he entered the resident’s room after Code Blue was called, he saw three nurses performing CPR. At that time, he informed them of the resident’s DNR status. The Director of Nursing (DON) was notified, and she instructed them to continue performing CPR until the paramedics arrived. According to the DON, continuing the CPR was in accordance with the facility’s policy. Therefore, the CPR continued for another 20 minutes. Cardiac resuscitation can often result in rib or sternal fractures due to the pressure being applied to the chest. The facility did not protect this resident her in the last moments of her life. Rather, they initiated a procedure that can cause further damage to the body. The facility’s lack of attention to their own procedures and policies shows a system-wide failure, one that could lead to the suffering of another resident.

The facility’s Medical Director said he was informed that CPR was initiated and continued until EMS arrived. He did not agree with the DON’s actions, arguing that CPR could have been stopped once she discovered the resident was a DNR. He said he was working with the facility
through the Quality Assurance Performance Improvement program to change the policy.

The Social Services Director (SSD) revealed she had spoken with the resident’s mother prior to the incident. Her mother confirmed she wanted the resident to be changed from a full code status to a DNR status. She felt her daughter had suffered long enough because her condition had been significantly declining for a long time. The SSD stated she received an order from the physician to change the resident to DNR status. She also had a State of Florida DNR order form completed and signed, and she changed the care plan to reflect the new DNR status. She met with the nurse on duty for the resident to discuss the changes, and he confirmed that he understood the resident now had a DNR status. Although the SSD and a nurse on duty confirmed the DNR status, this information was not communicated to the rest of the facility.

This citation shows the failure of this facility to care for a resident in accordance to her Advance Directives and end-of-life wishes. This resident received unwanted and potentially painful life-saving measures when she should have been able to pass peacefully. The facility’s negligence in checking a code status raises a red flag, because this is something that could happen to another resident if policies and procedures aren’t followed.

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