The incident occurred when Licensed Practical Nurse #150 was distributing morning medications and received an alert that Resident #52 had collapsed on the bathroom floor. The nurse rushed to provide care, but when the resident stopped breathing and lost their pulse, she immediately began cardiopulmonary resuscitation.
"CPR was initiated due to the resident not having signed DNR paperwork in the medical record," LPN #150 told federal inspectors during a telephone interview.
The resident had clear physician orders for "Do Not Resuscitate - Comfort Care Arrest" status in their medical chart. But the actual DNR paperwork that would have prevented resuscitation efforts was nowhere to be found when staff needed it most.
LPN #150 performed chest compressions while a certified nursing assistant manually ventilated the resident with a bag until a registered nurse took over. Emergency medical services arrived and continued treatment. The resident regained a pulse and was transported to the hospital.
The resident's medical history included metabolic encephalopathy, diabetes, Alzheimer's disease, and seizures. Their decision to refuse aggressive life-saving measures had been documented by their physician, but the facility's failure to maintain proper documentation meant their wishes were ignored during the crisis.
Director of Nursing confirmed to inspectors that Resident #52 had valid physician orders for comfort care status. She acknowledged the facility had failed to ensure the signed DNR paperwork was present in the medical record where staff could access it during emergencies.
This represents exactly the scenario DNR orders are designed to prevent. Residents who choose comfort care over aggressive interventions often do so after careful consideration of their medical conditions, quality of life, and personal values. The paperwork exists specifically to communicate those wishes to medical personnel during emergencies when the resident cannot speak for themselves.
The confusion occurred despite the facility having clear physician orders on file. A nursing progress note documented that Resident #51 had previously become unresponsive, with staff unable to find a pulse and beginning chest compressions before emergency services arrived. The inspection report indicates this may have involved the same documentation failures affecting multiple residents.
Federal inspectors found that 19 residents' advance directive records were reviewed as part of their investigation, with Resident #52 representing one case where proper DNR documentation was missing. The facility's census was 47 residents at the time of inspection.
The violation falls under federal regulations requiring nursing homes to honor residents' rights to refuse treatment and formulate advance directives. These protections exist because nursing home residents are particularly vulnerable during medical emergencies, when there may be little time to locate family members or review complex medical histories.
LPN #150's actions followed standard emergency protocols for residents without clear DNR orders. Nursing staff are trained to err on the side of life-saving interventions when documentation is unclear or missing. The fault lies with the facility's failure to maintain accessible records, not with the nurse's emergency response.
The incident highlights a critical gap in the facility's record-keeping systems. During medical emergencies, seconds matter, and staff must be able to quickly access residents' care preferences. When DNR paperwork is missing or misfiled, residents may receive exactly the aggressive interventions they specifically chose to avoid.
Monarch Meadows' documentation failure meant a resident experienced chest compressions, forced ventilation, and emergency transport despite having made a conscious decision to refuse such measures. The resident's medical conditions, including Alzheimer's disease, likely made the decision to pursue comfort care particularly significant.
The violation was investigated as part of a complaint filed with federal regulators. Inspectors classified the harm level as minimal, though the psychological and physical impact on a resident receiving unwanted medical interventions can be significant.
For families choosing nursing home care for loved ones with advance directives, the incident underscores the importance of verifying that facilities maintain accessible copies of DNR orders and other care preferences. The most carefully considered end-of-life decisions become meaningless if the paperwork isn't available when staff need it most.
The resident who received unwanted CPR had their final wishes ignored not through malicious intent, but through administrative failure that turned their comfort care directive into an empty promise.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Monarch Meadows Nursing and Rehabilitation from 2025-09-18 including all violations, facility responses, and corrective action plans.
Additional Resources
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