Solaris Healthcare Bayonet Point: DNR Ignored, CPR Done - FL
Then the resident became unresponsive during therapy.
A nurse checked the chart. It said full code. No pulse, no heart sounds, no respirations. CPR began. Only after the resuscitation was underway did anyone learn that the clerk had been holding the DNR form the whole time, received from the family about an hour before the resident stopped breathing.
Federal inspectors classified the failure as immediate jeopardy to resident health or safety.
The sequence of events, as documented in the September 2025 inspection report, started at admission. The resident could not confirm her own code status when she arrived, and her family did not have paperwork with them to establish it definitively. Staff designated her as full code in the meantime and told the family they would need to provide documentation before that status could change. The family eventually did exactly that. They handed the DNR form to a clerk.
That was the problem. The clerk was not a nurse. The clerk was not a unit manager. The clerk was, according to the facility's own root cause analysis, a non-direct-care staff member who received the form and did not immediately route it to someone with the authority to update the chart. The inspection report does not say where the clerk was, what she was doing, or whether she understood what she was holding. It says only that she had gone on break, and that she informed clerical staff about the form after she returned, by which point CPR was already in progress.
The nurse who initiated CPR had done nothing wrong by the chart in front of her. The order said full code. She followed it. The failure happened before she ever entered the room.
Facilities routinely admit residents whose code status is uncertain, and the practice of defaulting to full code while documentation is gathered is not unusual. What the inspection record describes at Solaris is a breakdown in what happens next: a family follows the instructions they were given, produces the paperwork, and hands it to someone at the facility who does not know, or does not act on, what to do with it.
The facility's response was extensive. A full audit of all 174 residents' charts was completed, cross-checking advance directives against the electronic medical record to confirm every resident's status was accurately reflected. Every single staff member received education, documented with written attestation. That included 120 nursing employees, 22 dietary workers, 22 environmental services staff, 21 therapy department employees, 9 administrative staff including bookkeepers and receptionists, 4 plant operations workers, and 3 recreation staff. The Medical Director participated by telephone. The Director of Nursing, the Administrator, and regional risk management were all involved.
The new rule, stated plainly in the inspection record: a nurse must be given the DNR, not a secretary or other staff.
The facility also conducted code status verification drills and documented staff interviews with dozens of employees across departments, all of whom confirmed they had received the education and understood what to do if a family member handed them an advance directive.
What the inspection report does not say is what happened to the resident after CPR was performed. Whether she survived, what condition she was in, what her family was told afterward — none of that appears in the record reviewed by inspectors. The report ends with compliance documentation, staff interview summaries, and attestation counts.
The family had done what the facility asked them to do. They got the paperwork. They brought it in. They handed it to someone at the front. And for the roughly sixty minutes that followed, their instructions for their loved one's final moments were sitting with a clerk on break, while the chart still said full code, while their family member was still in therapy, still alive.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Solaris Healthcare Bayonet Point from 2025-09-26 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 26, 2026 · Our methodology
Solaris Healthcare Bayonet Point in HUDSON, FL was cited for violations during a health inspection on September 26, 2025.
Then the resident became unresponsive during therapy.
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.