Hospital Cited For CPR on DNR Patient

By Walter F. Roche Jr.

An Allegheny County hospital has been cited by the Pennsylvania health officials for initiating resuscitation on a patient who had completed an advanced directive stating his desire not to have that happen.
The incident occurred in mid-July at the 328-bed St. Clair Hospital in Pittsburgh.
According to the recently released inspection report from the state Health Department, the unnamed male patient was brought to the hospital on July 17 from a personal care home. Hospital staff later verified that he was on hospice care at that facility, according to the report.
Several hours later the patient was found unresponsive and cardio pulmonary resuscitation was initiated, inspectors reported following an Aug. 14-15 visit to the hospital.
"The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives," the report states.
The report does not include any information on the results of the resuscitation efforts.
In response to questions about the report a hospital spokesman said that the facility had self reported the incident to the state.
"St. Clair Hospital recently reported to the Pennsylvania Health Department an event in which a patient transferred from a personal care home was resuscitated despite having earlier filed a "do not resuscitate" code status," the spokesman said.
He added that a plan of correction had been filed with the state and approved. It is now being implemented, according to the statement.
The plan calls for a series of training sessions for staffers with subsequent audits to ensure that directives are being followed. The hospital will also notify operators of personal care homes and assisted living facilities that send patients to St. Clair of its policies regarding advance patient directives.
Under the plan a patient's advance care directives will be entered on his or her record upon admission.
"The appropriate code status designation will be entered into the patient's medical record upon admission," the report states.
"This event underscore St. Clair Hospital's objective to ensure accurate communication regarding patient wishes about end-of-life care," the hospital statement continued.
In addition to the failure to follow a patient's directives, St. Clair was cited for failing to administer written orders of a practitioner and failure to ensure that cardiac monitoring equipment was functioning properly. A cardiac monitor had been ordered for the patient but the first reading was recorded only after he was found unresponsive, inspectors reported.
In response St. Clair said it would implement a plan to increase cardiac monitoring and to train staff on how to use the equipment.
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