North Capitol Nursing: DNR Resident Got CPR After Fall - IN
The incident was documented during a complaint inspection completed October 15, 2025.
Licensed Practical Nurse 2 was the first clinical staff member to respond. She ran to the memory care unit after being notified of the fall, checked the resident's code status, and found Resident B on the floor in the middle of a seizure, the back of her head bleeding what LPN 2 described as "a lot," her breathing producing a snoring sound. LPN 2 called 911. The dispatcher instructed her to initiate CPR. She performed what she later described as light chest compressions.
The resident came out of the seizure on her own. Her breathing returned to normal. EMS arrived, wrapped her head wound, placed a neck brace on her, and put her on oxygen. She was awake and breathing normally when the ambulance took her. She was back at the facility the same day, roughly eight hours later.
In an interview with inspectors, LPN 2 said she was "in the heat of the moment." It was the first time she had experienced a resident in that condition.
Resident B's representative learned about the fall from the facility. She was told it was unwitnessed, that the resident had seized, that she had a head injury to the back of her head, and that she had been transferred to the hospital. She was also told that staff had initiated CPR.
That last part was upsetting. The representative told inspectors that the resident was a DNR and that all the advanced directive paperwork was in her chart. The nursing staff, she said, had "acted in a panic mode."
A Qualified Medication Aide who walked onto the unit that morning observed Resident B on the floor with nursing staff around her. She saw LPN 2 performing CPR. EMS arrived and transferred the resident.
The facility's own advanced directives policy, provided to inspectors by the Executive Director, states that if a resident has a valid advanced directive, the facility's care will reflect the resident's wishes as expressed in that directive.
After the incident, LPN 2 received education. She was taught, according to the inspection record, about "moving in correct order," which the facility described as understanding the situation and code status before acting.
The citation was classified as minimal harm or potential for actual harm, affecting few residents. That classification does not mean nothing happened. Resident B hit her head hard enough to bleed heavily. She seized on the floor of the memory care unit. She spent eight hours in a hospital emergency room. And before EMS arrived, a nurse pressed on her chest, something her own documented wishes said should not happen.
LPN 2 told inspectors she checked the code status when she arrived. What she did next contradicted it.
The inspection report does not say whether Resident B was ever told that her wishes had not been followed. It does not say whether the facility reviewed how the DNR status was communicated to staff working that unit. It notes that the Assistant Director of Nursing handled notifications and paperwork after the incident, and that education was provided to LPN 2.
Her representative's word for what the staff did was "upsetting." That is the word in the record.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for North Capitol Nursing & Rehabilitation Center from 2025-10-15 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 25, 2026 · Our methodology
NORTH CAPITOL NURSING & REHABILITATION CENTER in INDIANAPOLIS, IN was cited for violations during a health inspection on October 15, 2025.
The incident was documented during a complaint inspection completed October 15, 2025.
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.