Salem West Healthcare: CPR Given Despite DNR Order - OH
The incident at Salem West Healthcare Center involved a resident with late-onset Alzheimer's disease who had signed a Do Not Resuscitate Comfort Care-Arrest order. The form explicitly stated that if a resident had a DNR, providers would not perform cardiopulmonary resuscitation.
When nurses found the resident cyanotic with only three breaths per minute, they grabbed a crash cart and called 911. Licensed Practical Nurse #115 initiated chest compressions while another nurse provided rescue breathing.
The resident's pulse stopped and breathing ceased during the resuscitation attempt. Emergency medical technicians arrived and scanned the resident's hospital bracelet, discovering the DNR order. Only then did staff stop CPR.
The resident died.
During interviews with federal investigators, the facility's Director of Nursing confirmed staff had violated the resident's wishes. She said she later educated nurses that residents with DNR orders should not receive CPR.
LPN #115 told investigators that neither she nor Registered Nurse #150 understood what the "A" at the end of "DNRCC-A" meant. The form they had ignored specified that residents with this designation should be treated normally until cardiac or respiratory arrest occurs, at which point all interventions must cease.
The resident's medical record showed a history of sudden cardiac arrest, hypertension, and cognitive communication deficits. He received nutrition through a gastrostomy tube.
A nursing note documented the sequence of events at 2:38 PM. The nurse found the resident cyanotic with severely depressed breathing. While one staff member retrieved oxygen supplies, LPN #115 grabbed the crash cart and another nurse called emergency services.
Staff performed one round of chest compressions and rescue breathing before confirming the resident had no pulse or respirations. Two nurses verified the absence of vital signs.
When EMTs arrived, they used their scanner to read the resident's hospital bracelet. The device immediately displayed his DNR status. Emergency personnel confirmed the resident was dead and took no further action.
A hospice nurse also responded to the facility and received an update on the resident's death.
The resident had signed his DNR Comfort Care-Arrest order on a specific date documented in his medical record. The form contained clear instructions about treatment limitations.
According to the directive, residents with DNRCC-A status should receive normal medical care until they experience cardiac or respiratory arrest. At that point, the DNR protocol takes effect and all life-sustaining interventions must stop immediately.
The form specifically prohibited cardiopulmonary resuscitation for residents who had signed it.
Federal investigators determined the facility failed to honor the resident's documented code status. The violation affected one of two residents reviewed for advance directive compliance.
During her interview, the Director of Nursing acknowledged the error and said she provided additional training to nursing staff about DNR protocols. She confirmed that CPR should never have been initiated given the resident's documented wishes.
The confusion expressed by nursing staff highlighted a fundamental gap in their understanding of advance directives. LPN #115's admission that she and the registered nurse didn't know what the "A" designation meant suggests inadequate training on end-of-life protocols.
The resident had multiple serious medical conditions that likely contributed to his decline. His history of sudden cardiac arrest may have made staff more inclined to intervene aggressively, despite his documented preferences.
The timing of the incident created additional stress. Staff discovered the resident in distress during what appeared to be his final moments. The combination of urgency and confusion about his DNR status led to the protocol violation.
Emergency medical technicians demonstrated the proper procedure by immediately checking the resident's code status upon arrival. Their scanner quickly identified his DNR order, confirming what facility staff should have known before beginning resuscitation efforts.
The presence of a hospice nurse suggests the resident was receiving end-of-life care. Hospice services typically involve detailed discussions about comfort care and treatment limitations, making the CPR incident more problematic.
Federal regulations require nursing homes to honor residents' advance directives and treatment preferences. Facilities must ensure staff understand these documents and can implement them correctly during medical emergencies.
The investigation occurred as part of a complaint filed against the facility. The specific nature of the complaint was not detailed in the inspection report, but the DNR violation represented a significant breach of the resident's autonomy.
Staff confusion about medical directives poses serious risks in nursing home settings, where many residents have complex advance directives reflecting their end-of-life preferences. Proper training and clear protocols are essential to prevent similar violations.
The resident's family had worked with him to establish his DNR status, documenting his wishes about end-of-life care. The facility's failure to honor those preferences undermined the careful planning they had undertaken together.
The incident occurred despite the resident having a clearly documented DNR order in his medical record. The form was properly signed and contained specific instructions that staff failed to follow during his final moments.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Salem West Healthcare Center from 2025-08-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
SALEM WEST HEALTHCARE CENTER in SALEM, OH was cited for violations during a health inspection on August 25, 2025.
The form explicitly stated that if a resident had a DNR, providers would not perform cardiopulmonary resuscitation.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.