OCONOMOWOC, WI - A resident at Lake Country Health Services experienced chest compressions despite wearing a Do-Not-Resuscitate bracelet and having documented DNR orders, leading to days of chest and back pain before the resident's death, according to a state inspection completed March 12, 2025.
Critical Medical Error Led to Unwanted Life-Saving Measures
The incident occurred when a registered nurse discovered the resident unresponsive and administered 12 to 15 chest compressions without verifying the resident's code status. The nurse later acknowledged not seeing the DNR bracelet on the resident's wrist before beginning CPR, though multiple staff members confirmed the bracelet was clearly visible.
According to the inspection report, the nurse stated there was no established process for calling a code at the facility and no portable phone system to contact other nurses for assistance. The nurse made a split-second decision to begin compressions rather than leave the resident alone to check code status on a computer system located outside the room.
The resident regained consciousness after the compressions but immediately began experiencing significant chest pain. A certified nursing assistant reported that the resident "complained of chest pain" that persisted until death several days later, with the resident stating "it hurts" during any care activities. Another staff member confirmed the resident experienced ongoing pain in both chest and back following the incident.
Systemic Failures in Emergency Response Protocols
The violation exposed multiple system-wide failures in the facility's emergency response procedures. Staff interviews revealed there was no standardized training on code procedures beyond basic CPR certification. New employees received only brief coverage of the topic during orientation, with no ongoing reinforcement or practice drills.
The facility's communication infrastructure proved inadequate for emergency situations. Without portable phones or an intercom system, nurses faced an impossible choice between leaving an unresponsive resident alone to verify code status or proceeding without confirmation. This structural deficit directly contributed to the violation of the resident's end-of-life wishes.
DNR verification protocols were inconsistent and poorly implemented. While residents could wear DNR bracelets, this was not a standardized requirement, and the facility failed to include bracelet usage in care plans even when residents chose to wear them. The electronic medical record system contained code status information, but accessing it required leaving the resident's bedside during critical moments.
Medical Impact of Unwanted Resuscitation
Chest compressions, when performed correctly, apply significant force to the ribcage to manually pump blood through the heart. This force can cause rib fractures, especially in elderly residents with more fragile bones. The sustained pain reported by this resident over multiple days suggests possible rib or cartilage damage from the compressions.
Beyond physical trauma, receiving unwanted resuscitation violates fundamental principles of patient autonomy and informed consent. Residents who choose DNR status have made deliberate decisions about their end-of-life care based on personal values, quality of life considerations, and medical understanding of their conditions. Overriding these wishes can cause psychological distress in addition to physical pain.
The delay between the incident and the resident's death meant days of unnecessary suffering that could have been avoided with proper protocols. Pain management becomes complicated when the source is iatrogenic - caused by medical intervention - especially when that intervention violated the patient's expressed wishes.
Additional Issues Identified
The inspection revealed several related deficiencies in the facility's operations. Management acknowledged that no comprehensive system existed for code status verification during emergencies. The facility lacked regular code drills or scenario-based training that could have prepared staff for rapid decision-making. Documentation practices were inconsistent, with DNR bracelet usage not recorded in care plans despite residents wearing them.
Following the incident, facility administration implemented corrective measures including mandatory education on code status verification, comprehensive audits of all residents' advance directives, and regular code drills. Management introduced "one minute management" interviews to verify staff knowledge retention. However, these reactive measures came too late for the affected resident.
The nurse involved was immediately suspended pending additional training. The facility's Administrator and Director of Nursing confirmed that while the nurse had CPR certification, the facility had not provided adequate training on its specific code response procedures or DNR verification protocols.
An anonymous staff member who witnessed the aftermath described the incident as "crazy," emphasizing how the presence of the visible DNR bracelet should have prevented the situation entirely. This observation underscored the preventable nature of this violation and its consequences.
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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