Life Care Center: CPR on DNR Patient - Idaho Falls
The September incident at Life Care Center of Idaho Falls began when a certified nursing assistant found Resident #5 unresponsive. Nursing staff assessed the patient and correctly determined she was designated DNR.
Then LPN #1 entered the room carrying a POST document and announced the resident was "a full code." CPR began immediately.
The POST document belonged to a different resident entirely.
Resident #5 had multiple, consistent DNR orders across her medical records. Her physician had written a DNR order. Her POST form specifically documented "do not resuscitate" while allowing aggressive interventions including positioning and oxygen therapy. Her care plan listed her code status as DNR.
Staff called 911 for an ambulance while continuing CPR.
When the ambulance crew arrived, facility staff had identified their error. They told paramedics that Resident #5 was DNR. CPR stopped. Time of death was called at 3:30 PM.
Two days later, the admissions nurse and RN #1 confirmed to inspectors that Resident #5 had been a DNR patient and "CPR should not have been started on her."
Resident #5 was initially admitted to the facility earlier in the year, then readmitted with multiple diagnoses including chronic kidney disease and diabetes. Federal inspectors reviewed her case as part of a complaint investigation completed in September.
The facility's own investigation documented the sequence of events. Staff found the resident unresponsive, correctly identified her DNR status during assessment, then reversed course when LPN #1 brought the wrong patient's POST document into the room.
POST forms, or Physician Orders for Scope of Treatment, are standardized medical documents that specify a patient's wishes for life-sustaining treatment. They follow patients across different care settings and are designed to prevent exactly this type of confusion about end-of-life care preferences.
Federal inspectors determined the facility "failed to honor residents Do Not Resuscitate (DNR) and Do Not Intubate (DNI) orders." They classified the violation as having "minimal harm or potential for actual harm" affecting few residents.
The inspection narrative does not indicate how long CPR continued before paramedics arrived. It also does not specify whether the facility has implemented new procedures to prevent staff from using the wrong patient's medical documents during emergency situations.
The violation represents a fundamental breakdown in following a resident's documented wishes about their own medical care. Federal regulations require nursing homes to honor residents' rights to "request, refuse, and/or discontinue treatment" and "formulate an advance directive."
Resident #5's case involved clear, consistent documentation across multiple medical records. Her physician order, POST form, and care plan all specified the same DNR status. The error occurred not because of unclear or conflicting instructions, but because staff used another patient's document.
The facility investigation documented that nursing staff initially performed the correct assessment and determined Resident #5 was DNR. The mistake happened when LPN #1 brought the wrong POST document into the room and announced the resident was "a full code," overriding the earlier correct assessment.
Inspectors noted this "deficient practice created the potential for harm or adverse outcomes if residents' wishes were not followed or documented." In this case, the resident's clearly documented wishes were not followed, despite being properly documented across her medical records.
The September 2 complaint inspection focused specifically on code status procedures. Inspectors reviewed one resident's record for this issue and found the violation in that single case they examined.
Federal surveyors completed their inspection and cited the facility for failing to honor advance directives. The violation falls under federal tag F 0578, which covers residents' rights to make decisions about their medical treatment.
Life Care Center of Idaho Falls must submit a plan of correction addressing how they will prevent similar incidents. The facility has not yet provided details about what changes they will implement to ensure staff use the correct patient's medical documents during emergency situations.
The case highlights the critical importance of accurate patient identification during medical emergencies. When staff grabbed the wrong POST document, they effectively imposed another resident's treatment preferences on Resident #5, directly contradicting her documented wishes about end-of-life care.
Resident #5's family had worked with medical providers to establish clear directives about her care. Those wishes were properly documented and consistently recorded across her medical records. The facility's error meant those carefully considered decisions were ignored during her final moments.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Life Care Center of Idaho Falls from 2025-09-02 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
Life Care Center of Idaho Falls in Idaho Falls, ID was cited for violations during a health inspection on September 2, 2025.
The September incident at Life Care Center of Idaho Falls began when a certified nursing assistant found Resident #5 unresponsive.
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.