OCONOMOWOC, WI - Federal inspectors found that Lake Country Health Services failed to honor a resident's do-not-resuscitate directive, administering chest compressions that caused extreme pain despite multiple DNR documentation and the resident wearing a DNR bracelet.
Resident Received Unwanted CPR Despite Multiple DNR Orders
The most serious violation occurred when a nurse administered CPR to a resident who had clearly documented wishes against life-saving measures. The resident, identified as R1, had signed state DNR forms, active physician orders documenting DNR status, and was wearing a DNR bracelet on their left wrist. Despite these multiple indicators, facility staff performed 12 to 15 chest compressions during a medical emergency.
The incident began when a certified nursing assistant found R1 unresponsive during bedtime care. The responding registered nurse found R1 "slumped and limp in the wheelchair" with cold, pale skin and blue-tinged lips. According to the inspection report, the nurse documented being "unable to ascertain the resident's code status at this time and situation" and proceeded to lower R1 to the floor and initiate CPR.
During interviews with investigators, the nurse explained the difficult situation: "R1 was experiencing a rapid decline and RN-F had to decide to follow protocol or stay with R1 and work with the information that RN-F had at hand." The nurse stated they could not establish DNR status without leaving the room to access a computer, so they "used nursing judgment and decided to start CPR."
Medical consequences were immediate and severe. The inspection report documented that R1 "complained of chest pain with movement after the compressions were given" and facility records showed R1's pain level as "extreme" following the incident.
Communication System Failures Created Emergency Response Barriers
The facility's emergency communication systems were found to be significantly compromised, potentially affecting the safety of all 82 residents. During the inspection, investigators discovered multiple system failures that could delay or prevent emergency response.
The phone paging system, which staff use to alert others of medical emergencies, was observed malfunctioning during the survey. When investigators requested a demonstration, they waited 23 minutes before hearing the first successful test page. The testing revealed volume adjustment issues, phones requiring restarts, and a "do not disturb" function that could prevent pages from being received.
Portable phones that nurses are expected to carry were not available on all four units. At the time of inspection, the 200-unit had no portable phone available, and the 400-unit's phone was charging after being recently replaced. Staff reported that phone reception was "poor and unreliable," with one nurse stating they avoid using the portable phone due to connection problems.
The facility's overhead paging system, which could provide building-wide emergency alerts, has been non-functional for years according to facility administrators. The maintenance director confirmed the system stopped working months ago during a fire drill, though the administrator stated it had been down for years.
Medical Analysis: Understanding the Risks of Unwanted CPR
CPR involves forceful chest compressions designed to manually pump blood through the body when the heart stops. While this procedure can save lives in appropriate circumstances, it carries significant medical risks, particularly for elderly residents with fragile health conditions.
Broken ribs represent the most common CPR complication. The force required for effective chest compressions frequently fractures ribs, especially in elderly patients whose bones are more brittle. These fractures are extremely painful and can lead to serious secondary complications if broken ribs puncture lungs, the spleen, or liver.
Brain injury risk increases substantially during CPR because the procedure typically delivers only 5% less oxygen than normal circulation. Brain damage can occur within 4 to 6 minutes of oxygen deprivation, with permanent damage likely after 10 minutes. For residents already experiencing multiple health conditions, this risk becomes particularly significant.
Other serious complications include aspiration pneumonia from vomiting during the procedure, internal organ damage from the force of compressions, and severe psychological trauma for survivors. These risks explain why many residents and families choose DNR status after considering their overall health outlook and quality of life preferences.
Industry Standards Require Clear DNR Protocols
Federal regulations mandate that nursing facilities honor residents' advance directives without exception. The Centers for Medicare & Medicaid Services require facilities to have clear policies ensuring residents' end-of-life wishes are respected and followed by all staff members.
Industry best practices dictate that code status information must be immediately accessible to responding nurses. This typically involves prominently displaying DNR status in electronic medical records, ensuring code status is communicated during shift changes, and training all staff on quickly locating advance directive information during emergencies.
The facility's own policies emphasized checking code status before beginning CPR. Facility documents instructed staff to verify whether "the chart read full code or DNR" before starting compressions. However, investigators found significant gaps in implementation, including inadequate staff training and communication system failures that prevented proper protocol execution.
The resident had been enrolled in hospice care with comfort measures as the goal, making the CPR administration particularly inappropriate. Hospice care specifically focuses on pain management and dignity rather than life-prolonging interventions.
Staff Training Deficiencies Created Dangerous Knowledge Gaps
The investigation revealed that nurses lacked adequate training on emergency procedures beyond basic CPR certification. The responding nurse told investigators they "does not recall receiving training from the facility on codes" and stated "there is not a process for calling a code."
New employee orientation materials failed to provide essential emergency information. While the facility's CPR training slide mentioned maintaining current certification and locating automated external defibrillators, it omitted critical details about code procedures and where to find advance directive information during emergencies.
The facility acknowledged these training gaps during the inspection and implemented immediate corrective measures. Administrators established weekly code drills on each shift for four weeks and began conducting staff interviews using case studies to validate understanding of proper emergency procedures.
Additional Issues Identified
Inspectors documented a significant medication error affecting the same resident. Following the CPR incident, R1 was prescribed scheduled morphine for severe chest and back pain but did not receive the full prescribed dosage during four consecutive administration opportunities.
The facility operated without a formal Code Blue policy, instead relying on various educational documents that contained conflicting instructions about emergency procedures. Staff members received inconsistent guidance about actions to take when alone with an unresponsive resident.
Administrative oversight failures included the DNR bracelet not being documented in the resident's care plan despite being visible to staff. This represented a missed opportunity to ensure all caregivers were aware of the resident's wishes through multiple communication channels.
The violations resulted in an immediate jeopardy finding due to the serious nature of violating fundamental resident rights. Federal regulators determined the facility's failures created a reasonable likelihood for serious harm to residents. The immediate jeopardy designation was removed after the facility implemented comprehensive corrective actions including staff re-education, system improvements, and enhanced monitoring procedures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lake Country Health Services from 2025-03-12 including all violations, facility responses, and corrective action plans.
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