Complaint Investigation Report

Allegation: Staff did not follow advanced directives and requests regarding resuscitative measures.

The complaint allegation alleges that staff did not perform Cardiopulmonary Resuscitation (CPR) or use an Automated External Defibrillator (AED) when a resident was found without a pulse and not breathing.

During the visit, the department conducted a file review and received and reviewed a copy of resident R1’s POLST form. The department observed on the form in section A Cardiopulmonary Resuscitation (CPR): If a patient has no pulse and is not breathing, R1 had indicated Do Not Attempt Resuscitation/DNR (Allow Natural Death). Additionally, the department received and reviewed a copy of Follow Up Encounter Notes from Senior Doc CA when R1’s Selective Code and Full Code were discussed with the Medical Power of Attorney and a medical professional. On 05/02/2023 the POLST was filled out and indicated A. Do Not Attempt Resuscitations/DNR (Allow Natural Death). The department observed on R1’s Face Sheet that the Code Status is DNAR/Do Not Attempt Resuscitation.

During interviews with Staff S1-S6, were asked if R1’s POLST was followed on 01/05/2025, six (6) out of six (6) stated they knew R1 was a DNAR and did not try to resuscitate.

The department interviewed the Nurse Practitioner that has been tending to R1 regularly, the Nurse Practitioner confirmed that the POLST on file was according to R1’s and his family’s wishes.