DNR Verification and Full Code Death Procedure in a Nursing Home

The 60-Second Decision That Determines Everything

A CNA finds a resident unresponsive at 2 a.m. The charge nurse arrives and checks for a pulse — nothing. Before doing anything else, she needs to answer one question: is there a valid Do Not Resuscitate order on file?

That answer determines the entire clinical trajectory. A confirmed DNR means the team proceeds with pronouncement, family notification, and post-mortem care. An absent or unclear DNR means the team must initiate CPR and activate emergency medical services immediately — regardless of the resident's age, prognosis, or the clinical futility of the attempt.

Getting this wrong in either direction creates catastrophic liability.

DNR Verification: The Step-by-Step Process

When a resident is found unresponsive, the charge nurse should verify code status through the following sequence:

Step 1: Check the electronic health record. Confirm the current DNR/POLST documentation and follow the facility's process for verifying that it is valid under applicable state rules. Look for the actual order, not just a notation in the care plan or social work notes.

Step 2: Verify the physical POLST or DNR form at the bedside. Many facilities keep a printed copy in a designated location — a red folder at the bedside, a binder on the unit, or a clearly marked section of the paper chart. The physical copy provides immediate confirmation when the EHR is slow to load at 2 a.m.

Step 3: Confirm the scope. A POLST or advance directive may include nuances beyond a simple DNR. Some residents have a DNR but want comfort measures continued. Others have specific instructions about intubation, IV fluids, or hospital transfer. Read the actual document, not just the code status flag.

Step 4: If you cannot locate a valid DNR, treat the resident as full code. This is not optional. In the absence of a verified order, the legal default is full resuscitation.

When the Resident Is Full Code

If no DNR is on file and the resident is found unresponsive without signs of obvious death (rigor mortis, lividity, decomposition), the staff must:

1. Initiate CPR immediately. Begin chest compressions and rescue breathing per current AHA guidelines
2. Activate EMS. Call 911 and request emergency transport
3. Notify the attending physician. The physician needs to be informed that resuscitation is in progress
4. Continue CPR until EMS arrives and assumes care. Facility staff cannot make the decision to stop resuscitation — that authority belongs to the physician or the EMS medical director

This applies even when the clinical outcome is virtually certain. A 97-year-old resident with end-stage dementia and multiple organ failure who has no DNR on file must receive CPR. The legal obligation does not account for clinical judgment about futility.

The Gray Areas That Create the Most Risk

The DNR that was "being processed." The family discussed a DNR with the physician last week. The physician agreed. But the order was never signed in the EHR, and no physical form was completed. This resident is legally full code. Verbal agreements and family discussions do not constitute a valid order.

The POLST from another facility. The resident transferred from a hospital with a POLST form, but its validity at the receiving facility has not been confirmed. POLST requirements vary by state; check the applicable state rules and facility protocol.

The family member who says "don't resuscitate" at the bedside. A daughter standing at the bedside saying "Mom wouldn't have wanted this" is not a DNR order. Without a signed physician order, the legal obligation to resuscitate remains in effect. The family's verbal instruction does not override the absence of documentation.

Conflicting family opinions. One adult child wants everything done; another says their parent wanted comfort care only. Unless there is a signed advance directive or POLST that resolves the conflict, the default is full code. Document the family disagreement and notify the attending physician immediately.

Preventing the Ambiguity

The best time to verify code status is not at 2 a.m. when a resident is found unresponsive. It is during admission, during quarterly care conferences, and whenever the resident's clinical condition changes significantly.

Every resident's code status should be reviewed and confirmed at these intervals, with the physician order clearly documented in the EHR and a physical copy accessible at the bedside. The social worker should ensure that the family understands what the current code status means and has had an opportunity to discuss any changes.

The Nursing Home Staff — Family Communication After Death toolkit includes a DNR verification checklist and a code status decision flowchart that walks staff through the entire process — from initial discovery through pronouncement or resuscitation — so the right decision happens every time, even at 2 a.m.