Good Samaritan Sioux Falls: CPR Given to DNR Patient - SD
The resident had a physician's order for do-not-resuscitate status on file at Good Samaritan Society Sioux Falls Center. Staff discovered this only after emergency medical technicians arrived and someone finally looked at the advance directives binder.
Director of nursing B was working near the resident's room when restorative nursing aide V discovered resident 100 unresponsive. DON B entered the room, assessed the resident, and determined she was not breathing.
DON B asked certified nursing assistant K about the resident's code status. CNA K told her the resident was a full code, meaning all life-sustaining measures should be used during a medical emergency.
Registered nurse W brought the crash cart to the room and gave a second verbal confirmation that resident 100 was a full code. DON B initiated CPR, requested the automated external defibrillator, and called 911.
DON B provided CPR until emergency medical technicians arrived and took over treatment.
Only then did DON B look at the advanced directives binder on the crash cart. She read that resident 100 had a DNR code status. The written DNR order was provided to the EMTs, and CPR was stopped.
"If she had known that resident 100 had a DNR code status, she would not have started CPR on resident 100," DON B told inspectors. "There had been a miscommunication."
CNA K admitted she had not looked at the advance directives binder when she told DON B the resident was a full code. "She thought that resident 100 was a full code," according to the inspection report.
The facility's own policy required staff to obtain the crash cart and the advance directives binder to confirm a resident's code status before initiating CPR when someone was found unresponsive.
Clinical learning development specialist F, who conducted nursing staff training and competencies, told inspectors that when a resident was found unresponsive, staff were trained to check the resident's vitals, obtain the crash cart and the advance directives binder to confirm code status before starting CPR.
"She expected that CPR would not be initiated if a resident had a DNR code status," the report stated. "She stated that it was the facility's policy for the nurse to check the resident's code status before starting CPR."
The facility's Advance Directive including Cardiopulmonary Resuscitation and Automated External Defibrillator policy specified that if cardiac arrest occurs, CPR must be initiated unless the resident has a valid DNR order on file that includes a medical order issued by a physician.
Resident 100 had such an order. The physician had written the DNR directive, and it was properly filed in the advance directives binder that sits on the crash cart specifically for emergency situations like this one.
The advance directives binder and the residents' electronic medical records both identified each resident's physician-ordered code status, according to clinical learning development specialist F.
Yet two staff members gave verbal confirmations that the resident was a full code without consulting either resource. The director of nursing performed CPR for several minutes on a woman who had specifically requested that such measures not be taken.
The facility reported the incident to the South Dakota Department of Health as required. In that report, administrators acknowledged that CPR was initiated and EMS was called before the resident's DNR order was brought to the room. They noted that the code status was found via the advanced directive binder on the crash cart per policy and procedure.
Upon EMS arrival, the resident's DNR status was confirmed and the unwanted life-saving measures were stopped.
The facility stated in its incident report that policy was followed, though the inspection findings suggest the policy requiring verification of code status before initiating CPR was not actually implemented during the emergency response.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Good Samaritan Society Sioux Falls Center from 2025-09-05 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
GOOD SAMARITAN SOCIETY SIOUX FALLS CENTER in SIOUX FALLS, SD was cited for violations during a health inspection on September 5, 2025.
The resident had a physician's order for do-not-resuscitate status on file at Good Samaritan Society Sioux Falls Center.
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.