Hospitals and nursing homes in Kentucky are being encouraged to use purple wristbands with the letters "DNR" to signal that a patient does not want to be resuscitated.
But they are not required to use the wristbands, in spite of at least seven citations to nursing homes and personal care homes since 2007 as a result of alleged resuscitation mistakes.
Beginning in March, the Kentucky Hospital Association will encourage member hospitals to use purple bands.
"We've had a request from a number of hospitals in recent months to put out some guidance," said Elizabeth Cobb, vice president of health policy for the hospital group.
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Cobb said she knew of no mistakes involving do-not-resuscitate orders in Kentucky hospitals.
Of the seven citations issued by the Cabinet for Health and Family Services' Office of Inspector General to long-term care homes, the latest was last month in Caldwell County at Highland Homes. It is a personal care home, a facility that offers less skilled care than a nursing home.
In that case, state nursing home investigators cited the facility because the staff did not try to resuscitate a resident who was unresponsive on Jan. 3.
There was no documented evidence that the resident or the resident's state guardian had requested a do-not-resuscitate order, according to the citation, which was obtained under the state Open Records Act.
A nurse knew the resident required CPR, but the nurse, an assistant administrator and a maintenance supervisor all failed to call 911 or to initiate CPR, the citation said. The resident was not identified.
Highland Homes officials did not return telephone calls last week asking for comment.
John Karem, who had complained to the state that his mother received CPR at a Louisville nursing home even though she had do-not-resuscitate orders on file, said he had asked the Office of Inspector General and the Kentucky Hospital Association to begin using purple wristbands.
In 2009, Karem and others who wanted a state regulation requiring the use of purple wristbands reached a compromise with nursing home industry officials who fought the regulation, said Bernie Vonderheide, founder of Kentuckians for Nursing Home Reform. One industry concern was that the wristbands would compromise patients' confidentiality.
Instead of a regulation, the Office of Inspector General issued a best practices bulletin, saying nursing homes should offer a purple band to residents with DNR orders. A residents may opt out of wearing a wristband, according to the bulletin.
DNR orders in charts
Federal and state laws require that hospitals and nursing homes keep a patient's DNR orders in their charts. Currently, the way the facilities convey the order varies.
Even when a colored wristband is being used, "health care personnel are not supposed to act on a wristband alone, but they are directed to check the chart in order to get the full order," said Cobb, of the Kentucky Hospital Association. "The chart is the most important piece to caring for the patient."
The state gives an initial supply of purple wristbands free to any facility that requests them, cabinet spokeswoman Gwenda Bond said. At least 11 nursing homes have made such requests.
Cabinet spokeswoman Beth Fisher said the Office of Inspector General continues "to educate administrators and staff about DNR orders and the need for proper identification of DNR patients."
Karem said in an interview Sunday that his next step was to survey nursing homes to see how many are using the wristbands and to encourage more facilities to use them.
Cobb said the hospital association will begin distributing a DNR tool kit on March 30 so its 127 members may "decide whether or not it's the right program for them."
The hospital association also is endorsing the use of red wristbands with the world allergy on them and yellow bands to indicate patients are at risk of falls, she said.
Cobb said the Kentucky group is following the lead of the American Hospital Association, which suggests that hospitals with wristband systems use only purple, red and yellow.
According to the American Hospital Association Web site, standardization is needed because many doctors and nurses work at multiple hospitals. If hospitals use other wristband colors for those three alerts, the risk of mistakes increases.
More than 25 state hospital associations have provided their hospitals with the voluntary guidelines, the Web site said.