Errors at Bedside of Dying Residents: Kentucky Law Loophole Needs Closure
Resuscitate or no resuscitation? This question is the center of controversy in Kentucky where there is a gap in Kentucky law that has led to resuscitation errors.
In February 2008, Jefferson Manor Nursing Home staff in Louisville, Kentucky performed CPR on 95 year old Eva Karem despite the do not resuscitate (DNR) order on file. The DNR order was sent to Jefferson Manor by her physician the day before she died.
On December 24, 2008, Woodland Oaks Healthcare Center in Ashland, Kentucky failed to perform CPR on a dying resident despite the signed DNR order in her file. Woodland Oaks was assessed a Type A citation - the most serious citation possible - for the error.
These errors point to a hole in Kentucky law: there is no uniform regulation about how to denote a patient's wishes regarding resuscitation in a long-term care facility or hospital. Federal and state laws require that hospitals and nursing homes keep DNR orders in a patient's chart. Carrying out those orders appears to be where problems arise. Some facilities opt to use color-coded wrist bands, others use colored tape on doors or stickers in charts.
Nursing Home groups are trying to determine whether or not guidelines should be the subject of proposed legislation in the General Assembly or simply added to existing regulations. They are also researching the best way to clearly state the patient's wishes. Currently, there is no uniform color-coded wristband for a DNR order. California researchers have determined that a uniform color-coded wristband used nationwide would help prevent errors. Color-coded wrist bands would be cost-effective and could eliminate confusion.
