Recently there has been an increase in citations related to advanced directives, specifically Do No Resuscitate Orders not being followed properly. So, what is required?
To get it right, start with your policies and procedures. Each assisted living facility must have written policies and procedures that explain its implementation of state laws and rules relative to Do Not Resuscitate Orders (DNROs). An assisted living facility may not require execution of a DNRO as a condition of admission or treatment.
When a resident is admitted, it is required that he/she or the resident representative receives information related to advanced directives from form SCHS-4-2006, “Health Care Advance Directives – The Patient’s Right to Decide,” April 2006, or with a copy of a document with very similar information, which incorporates information regarding advance directives. Form SCHC=4-2006 can be found here.
It is also required to give them a copy of DH Form 1896, Florida Do Not Resuscitate Order Form December, 2004. This form may be obtained by either calling the Department of Health’s toll free number (800) 226-1911, extension 2780 or online here. The DH Form 1896 is known to most as the “Yellow Do Not Resuscitate Order.”
Another required action is that there must be documentation in the resident’s record indicating whether a DH Form 1896 has been executed. If a DH Form 1896 has been executed, a yellow copy of that document must be made a part of the resident’s record. If the facility does not receive a copy of a resident’s executed DH Form 1896, the assisted living facility must document in the resident’s record that it has requested a copy. This is a great place to have follow up with the resident and family to see how the admission process has gone and to remind them of this needed form a few days after initially informed. It is not required to continue to ask the resident or the family, but good follow up might reduce some future problems concerning the actual wishes of the resident. It must be kept available for medical staff in the case of an emergency.
For you to get it right and be in compliance with 429.255, F.S., an assisted living facility must honor a properly executed DH Form 1896 as follows:
(a) In the event a resident experiences cardiac or pulmonary arrest, staff trained in cardiopulmonary resuscitation (CPR) or a health care provider present in the facility, may withhold cardiopulmonary resuscitation (artificial ventilation, cardiac compression, endotracheal intubation and defibrillation).
(b) In the event a resident is receiving hospice services and experiences cardiac or pulmonary arrest, facility staff must immediately contact hospice staff. The hospice procedures take precedence over those of the assisted living facility.
Training staff is extremely important and required. Newly-hired facility administrators, managers, direct care staff and staff involved in resident admissions must receive at least one hour of training in the facility’s policy and procedures regarding DNROs within 30 days after employment. Documentation that the staff member possess current CPR certification that requires the student to demonstrate, in person, that he or she is able to perform CPR and which is issued by an instructor or training provider that is approved to provide CPR training by the American Red Cross, the American Heart Association, the National Safety Council, or an organization whose training is accredited by the Commission on Accreditation for Pre-Hospital Continuing Education satisfies this requirement.
A staff member who has completed courses in First Aid and CPR and holds a currently valid card documenting completion of such courses must be in the facility at all times.
If a facility does not honor advanced directives, including CPR, it becomes a situation that meets the definition of an “adverse incident.” An adverse incident is an event over which facility personnel could exercise control rather than resulting from the resident’s condition. Adverse incidents also result from any condition that required medical attention to which the resident has not given his or her consent, including failure to honor advanced directives.
When the proper steps are in place, how do you know it is right? Dealing with DRNOs is a critical process that must be done right. It is best practice to audit to see if you are meeting the requirements and your policies.
But how do you know the staff really know what to do in a critical situation? Do you do DNR Drills? It is not a requirement, but it is the only way to really see if the staff can respond to a CPR situation properly and to a DNR situation properly. Yes, when the staff member obtains the CPR card, they should be proficient in the process of CPR, but this is about knowing where to find out if a resident is or is not a full code. Where is the AED stored? What do you do when the person who has CPR is not the one that found an unresponsive resident? Do you have a copy of the DNRO Yellow Form available for the appropriate residents? What if a resident goes to the hospital, who obtains more copies for future needs? There are many things to learn and review in these drills.
To get it right, you need to review the policy, process, and practice regularly so that staff who may have never been in a critical situation are prepared and confident that they will make the correct decision to meet the resident’s order and wishes when it comes to Do Not Resuscitate Orders.