FEDERAL WAY, WA - A state inspection revealed Life Care Center of Federal Way administered CPR to a resident with Do Not Resuscitate (DNR) orders after staff misidentified the patient during a medical emergency, violating the resident's documented end-of-life wishes.
Emergency Response Breakdown Leads to DNR Violation
During a medical emergency on an unspecified date, staff at Life Care Center of Federal Way initiated CPR on Resident 32, who had explicit Do Not Resuscitate orders documented in their Physician's Orders for Life Sustaining Treatment (POLST) form. The violation occurred when multiple staff members responded to a Code Blue alert but failed to correctly identify which resident required assistance.
According to the inspection report, when a housekeeper discovered Resident 32 unresponsive and called a Code Blue for room 207, the Infection Preventionist consulted the POLST book at the nurse station and incorrectly announced "207, bed 1 - full code, selective treatment." This misinformation prompted three nurses to begin CPR on Resident 32, whose orders specified selective treatment without CPR.
The Infection Preventionist stated during the inspection: "I heard the housekeeper say it was for room 207, bed 1. I looked at the POLST book and called out 207, bed 1 - full code, selective treatment." Only after CPR had already been initiated did staff realize the error and correct the information to reflect Resident 32's actual DNR status. By that point, medical protocols required continuing CPR until paramedics arrived and took over treatment.
The facility's Interim Director of Nursing confirmed the incident, explaining that once CPR begins, it must continue until emergency medical services arrive, regardless of discovered DNR orders. The violation represents a fundamental breakdown in the facility's system for protecting residents' end-of-life care choices.
Missing POLST Documentation Creates Additional Risks
The inspection uncovered systemic problems with the facility's POLST documentation system. Two additional residents, identified as Residents 16 and 60, had no POLST forms available in the designated POLST book at the nurse station, which serves as the primary reference point during medical emergencies.
When surveyors reviewed the POLST book on the inspection date, they found no documentation for Resident 16, who had intact memory and had been admitted with diagnoses including anemia and a right femur fracture. Staff searched multiple locations, including the resident's chart and medical records department, but could not locate the critical document. The Director of Nursing ultimately confirmed they were unable to find Resident 16's POLST and acknowledged the resident would need to complete a new form.
Similarly, Resident 60's POLST was missing from the book during the inspection. The Director of Nursing confirmed the POLST book serves as the first place nurses check during emergencies, making these omissions particularly dangerous.
Organizational Failures in Emergency Protocols
The facility identified the root cause of the CPR incident as their practice of organizing the POLST book by room number rather than resident name, creating opportunities for confusion during high-stress emergency situations. This organizational method proved inadequate when staff needed to quickly verify a resident's resuscitation preferences.
The facility's own CPR policy, dated appropriately, requires staff to verify whether residents have advance directives upon admission and obtain physician orders reflecting DNR status when applicable. The Advanced Directives and Advanced Care Planning policy further mandates that the Director of Nursing establish a system to inform all direct care staff of residents' DNR status. These policies were not effectively implemented.
The medical implications of performing CPR against a resident's wishes extend beyond the immediate physical trauma. CPR involves chest compressions that can fracture ribs, especially in elderly patients with fragile bones. The procedure can cause internal injuries, bruising, and significant pain if the patient survives. For residents who have chosen DNR status based on their medical conditions and quality of life preferences, unwanted resuscitation can result in prolonged suffering, extended hospitalization, and death occurring under circumstances they specifically sought to avoid.
Pattern of Care Failures Across Multiple Areas
The inspection revealed additional concerning patterns of care failures throughout the facility. Five residents lacked access to fresh water, with multiple residents reporting staff only provided water when specifically requested. Observations over several days confirmed water pitchers remained empty for Residents 8, 14, 13, 69, and 64, despite facility policy requiring fluids be offered and available to all residents.
The facility also failed to provide adequate bathing assistance to Resident 139, who received only one bed bath in 18 days despite requiring maximal assistance with bathing and having a highly transmissible gastrointestinal infection requiring isolation. The resident's fingernails were observed to be long and soiled, with the resident stating they needed help to trim them.
Hot water temperatures exceeded safe limits across multiple units, with measurements reaching up to 125.1°F in resident-accessible areas. The facility's own policy acknowledges that water at 120°F can cause third-degree burns with five minutes of exposure, with risk increasing as temperatures rise. Maintenance staff later identified a failed component in the hot water line requiring repair.
Communication Barriers for Non-English Speaking Residents
The facility failed to provide necessary translation services and communication aids for Resident 77, whose primary language was not English. Despite care plan requirements to post translator phone numbers and provide communication boards, the resident received neither. The resident reported that when staff didn't understand their requests, "they would walk away and not respond."
The Unit Care Coordinator acknowledged they had not provided the required communication assistance but should have, recognizing the importance of ensuring residents can make themselves understood and understand others. This failure left the resident unable to effectively communicate basic needs or participate in their care decisions.
Medical Supply and Safety Concerns
A resident requiring oxygen therapy for chronic obstructive pulmonary disease repeatedly received incorrect oxygen flow rates, with staff administering 3 liters per minute instead of the prescribed 2 liters. On one occasion, surveyors found the oxygen tubing lying on the floor, disconnected from the concentrator entirely. Incorrect oxygen administration can worsen respiratory conditions, cause carbon dioxide retention, and lead to respiratory failure in COPD patients.
The facility also failed to secure potentially dangerous items, with staff leaving razors and disinfectant cleaner accessible to a resident who was left unattended in a shower room. The staff member acknowledged leaving residents unattended violated protocol and that chemicals and sharps should have been locked up for resident safety.
Implications for Resident Rights and Safety
These violations demonstrate systematic failures in protecting resident autonomy, safety, and dignity. The DNR violation represents perhaps the most profound breach of resident rights - the fundamental right to control one's own end-of-life care decisions. When healthcare facilities fail to honor these documented preferences, they violate not only regulations but also the deep trust residents place in their caregivers.
The pattern of missing POLST documentation suggests inadequate systems for managing critical medical information. In emergency situations, seconds matter, and the inability to quickly access accurate resuscitation preferences can lead to irreversible consequences. The facility's acknowledgment that staff would need to continue unwanted CPR once started underscores the importance of preventing such errors through robust documentation and communication systems.
For the complete investigation findings and the facility's corrective action plans, refer to the full state inspection report available through the Washington State Department of Health.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Life Care Center of Federal Way from 2025-03-18 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.