IDPH has cited and fined Center Home Hispanic Elderly when the facility failed to provide emergency treatment and care to a resident, resulting in a nearly six hour delay in the administration of oxygen. A staff member mistakenly believed that “if a person has a DNR there are no interventions that should be provided.”
The resident in question was found at approximately 3:20am with hands that were cool to the touch and their oxygen saturation at 84%. Instead of immediately administering oxygen, the Licensed Practical Nurse (LPN) simply noted “resident DNR will continue to monitor” in the progress notes. At 6:00am, the resident’s SPo2 had dropped even further to 82%, yet the LPN still did not administer oxygen.
This failure to act was based on the LPN’s misinterpretation of the resident’s Do Not Resuscitate (DNR) status. In an interview the LPN stated, “if a person has a DNR there are no interventions that should be provided and with a DNR you should keep the the resident cleaned and comfortable.” This statement suggests a lack of understanding regarding the appropriate care for a resident with a DNR order.
The resident’s Physician Orders for Life-Sustaining Treatment (POLST) specified that while no CPR should be attempted, comfort-focused treatment should include the use of oxygen. The Director of Nursing (DON) reinforced this in an interview, stating, “DNR does not mean that a nurse does not provide care and care still needs to be provided.”
The LPN’s decision not to administer oxygen, despite the clear indication to do so based on the resident’s low SPo2 levels and the POLST, resulted in a significant delay in the resident receiving necessary care. It was not until 6:57am, when another nurse assessed the resident, that oxygen was finally administered. By this time, the resident’s condition had deteriorated to the point of requiring emergency hospitalization. Unfortunately the resident died the next day at the hospital.
This incident highlights the importance of ensuring that all nursing staff, including LPNs, fully understand the implications of a DNR order and the appropriate interventions that should still be provided to ensure patient comfort and well-being. The failure to administer oxygen in a timely manner, as a result of misinterpreting the DNR order, led to severe consequences for the resident
One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.
