Nurses at a Syracuse long-term care facility saved a resident’s life using cardiopulmonary resuscitation, even though the woman had a valid do-not-resuscitate order and was wearing a special bracelet to identify DNR patients.
The woman’s records stated she did not want to be resuscitated or intubated, wanted limited medical interventions and wished to be sent to the hospital only if necessary, according to a state Health Department inspection.
But nurses at the former James Square Health and Rehabilitation Centre took all of those steps after they found her unresponsive and without a pulse on Aug 13., Syracuse.com reported.
By the time a nurse noticed the DNR in the woman’s chart, she had already been taken to the hospital by ambulance.
The nurse who called for help after finding the woman unresponsive said hadn’t been trained on identifying DNR residents, according to Syracuse.com.
The facility was sold in December and renamed Bishop Rehabilitation & Nursing Center. New Administrator Margaret Mary Wagner said she was not familiar with the incident but told Syracuse.com, “This is a human business and people are going to make mistakes.”
“When something like that happens you have to do a root cause analysis [and] then change the process,” she added.
The inspection report describes the patient as an amputee with chronic pain, anxiety and cognitive impairment. It also describes how the five nurses who responded to the emergency failed to check the patient’s paperwork before starting or participating in CPR.
The home’s DNR-designated residents wear white and black bracelets and have red dots on their headboards as easy-to-spot reminders.
The home agreed to better educate nurses on determining whether advance directives exist.
After a hospital evaluation, the woman returned to the home unharmed, according to state documents.