“It seemed like nobody cared,” Charles Milne said.
While severe, the allegations in the case highlight a persistent issue that puts residents and patients at risk in senior care facilities across Georgia. Facility employees often have trouble completing, filing or identifying patient DNRs, an Atlanta Journal-Constitution analysis found.
The newspaper identified more than 100 Georgia Department of Community Health (DCH) investigations where DNR paperwork or practices were not properly followed in nursing homes, assisted living facilities and personal care homes in the past five years. And in some cases, staff failed to administer CPR and residents died, even though their medical record indicated they wanted to be resuscitated.
Patient care advocates say the situation in Georgia is part of a broader nationwide crisis that puts lives at risk and violates a facility resident’s dignity to choose how they will live and die.
“We’ve done very little — Georgia or anybody — to make sure that nursing homes train, understand and have the records to guarantee that [DNRs] will be honored,” New York University professor and medical ethicist Arthur Caplan said. “The infrastructure is not there.”
Confusion and consequences: The Department of Community Health’s DNR investigations
Incomplete paperwork. Contradictory DNR statuses. Staff uncertainty about a resident’s DNR standing.
All of the above have happened in Georgia’s nursing homes, assisted living facilities and personal care homes — and sometimes, the consequences are deadly, the AJC review found.
Typically, nursing homes and other senior care facilities ask incoming residents if they want to be resuscitated or not in the event of a medical crisis. Their response should be documented in their file. Staff are supposed to refer to their record for guidance on whether or not to try to resuscitate the patient if their heart or breathing stops.
If a patient doesn’t want to be resuscitated, a DNR order should be written down and placed in their file. Oftentimes, residents who choose DNRs are terminally ill or so frail that their body cannot handle the sometimes brutal side effects of CPR, like cracked ribs or torn organs.
But even with the written directives, resident wishes aren’t always followed, records show.
Two nursing home residents at Laurel Park Skilled Nursing and Rehabilitation in Stockbridge died after staff mistakenly thought they had DNRs, according to a DCH report in 2019. In one of the deaths, staff administered CPR to the resident an hour after they were found unresponsive. It took that long for staff to locate the person’s form that indicated they wanted to be revived, records show.
In a written statement, the facility’s parent company PruittHealth said it is committed to transparency and compliance.
“We continually work with federal and state regulators to identify and address areas of potential concern,” PruittHealth spokeswoman Tonja Bridges wrote in an email.
In cases at other facilities, staff sometimes took too long to find a patient’s DNR status — like in the Suites at Willow Pond, a senior living facility in Statesboro. Emergency Medical Services (EMS) personnel arrived after a call in 2017 to find three staff members standing around an unresponsive resident slumped over in a wheelchair, according to DCH records.
When the responders asked what was happening, a staff member at the facility left to fetch the resident’s DNR status, finding it “some time later,” the report said. EMS attempted CPR afterward and transferred the resident to the hospital, but the resident died, records said.
The current executive director of the Suites at Willow Pond declined to comment, saying she did not work at the facility in 2017.
And in some cases, it wasn’t clear if a patient had the cognitive awareness to understand they were signing a DNR.
At Bountiful Hills Senior Living in Commerce, an assisted living resident indicated in 2020 that they wanted a DNR. But the facility failed to have the person sign the correct forms, records show.
More than year later, as the resident’s health declined, a staff member had the resident sign the DNR form, a 2021 DCH report said. By that time, the resident who had been diagnosed with dementia was lethargic and not able to speak, the report said. This chain of events concerned an unnamed witness who said the resident was in no condition to make these type of decisions or “consent to anything,” records show.
DCH cited the facility for failing to support resident rights. But Nicholas Terzulli, Bountiful Hills’ attorney, maintains that the facility did not mishandle the resident’s DNR.
“End of life decisions are always difficult, and our staff works diligently with residents and families alike to ensure compassionate care,” he wrote in an email statement.
DNR confusion in senior care living facilities isn’t new, said Caplan, the medical ethicist — and it can’t be attributed to a single cause. Sometimes it happens because U.S. healthcare facilities lack a universal system of record-keeping, which can cause paperwork to fall between the cracks. Sometimes it’s because of a baked-in age and disability bias, where people don’t account for the wishes of a vulnerable senior, he said.
But most often, it’s because facilities don’t invest enough in their staff, who are usually undertrained and underpaid, according to Caplan. Many facilities are also stretched thin trying to care for so many residents, he said.
“People who go in there unaccompanied or become demented, they can’t look out for themselves,” Caplan said. “And they’re getting taken care of by people who are barely making what they get at Burger King.”
“This can’t keep happening”
Leona Milne was admitted to Roselane Health and Rehabilitation Center in Marietta in April 2018 to recover from a toe amputation. She had atrial fibrillation, a condition that causes an abnormal heartbeat, but was otherwise in relatively good health, according to her family.
Intellectually disabled since childhood, she had the mental capacity of a 10-year-old, according to her family’s lawsuit. Still, the day after her arrival, Leona was allowed to sign a DNR at Roselane. Her brother and caretaker, Charles Milne, did not know, according to the suit.
Leona’s DNR form was a part of a pattern of more than 190 forms that the nursing home had improperly filled out, the suit alleges. The facility used forms photocopied with pre-existing physician signatures instead of having a physician evaluate each patient’s situation in person, according to the suit. In Leona’s case — and in about half of the other DNRs — the form had the signature of a physician who had left the facility months before it was signed by the patient, the suit alleges. The forms were also never reviewed by an ethics committee as per law, the suit says.
Credit: HYOSUB SHIN / AJC
Credit: HYOSUB SHIN / AJC
The facility and its parent company, SavaSeniorCare, did not respond when the AJC reached out for comment. The company resolved its part in the lawsuit after an undisclosed financial settlement in 2021. But Charles Milne has continued to try to hold Leona’s primary physician at the facility accountable. In May, he transferred the lawsuit and named her as a defendant responsible for Leona’s death.
“There’s no comeback from a DNR,” said Michael Prieto, the family’s attorney. “This lady was deprived an opportunity to recover.”
The doctor, through her attorney, declined to comment. The suit says that her negligent oversight of patient medical records contributed to Leona’s death.
Charles says his sister’s death still haunts him. He remembers being stuck in standstill traffic along Ga. 400 when he received the phone call about her breathing problems.
“I couldn’t get there. The anguish I went through,” Charles said. “I keep re-living the ride down 400.”
Do-not-resuscitate orders explained
A do-not-resuscitate order, or DNR, is a medical order in a person’s file that instructs healthcare providers to not administer CPR if a patient’s breathing or heart stops. Typical DNR candidates include people with terminal illnesses or whose bodies cannot handle CPR, which can break ribs and damage organs.
In Georgia, adults capable of making decisions can consent to a DNR and cancel it anytime. Their physician can also cancel the DNR if they believe the patient should no longer be a DNR candidate.
Someone with power of attorney or a health care worker under an advance directive can also consent for the person under their care to have a DNR, if that person is not capable of making the decision on his or her own. However, facilities must consider what the person would have wanted if the person could understand the circumstances.
In situations where nobody is competent or available to make a decision and the adult is receiving treatment from a health care facility that isn’t a hospice or home health agency, the DNR goes through a two-step process before it can become valid:
1) Two physicians review and sign the DNR, which goes in the patient’s medical record.
2) An ethics committee reviews the DNR.
This two-step process often applies to the most vulnerable residents and patients in senior care facilities, many that have cognitive issues that impair their decision-making abilities. Charles Milne’s lawsuit alleges that his sister, Leona, should have received this type of review.
To learn more about DNRs, you can read the Georgia health code here.