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Woman Dies at Warren Barr North Shore After Staff Misread Chart

A 52 year old woman has died after a nursing assistant did nothing to resuscitate her, even though she was not a DNR patient. A DNR refers to a ‘Do Not Resuscitate’ order, a legal document that indicates a patient does not wish to be resuscitated in the event of a life threatening emergency. The form must be present in a patient’s file in order for that person to be considered ‘DNR’ and the lack of such a document indicates the patient would like all measures to be taken to keep them alive.

Mrs. Kimberly Cencula was a short term resident at Warren Barr North Shore in Highland Park, Illinois, there to receive physical therapy after a bout of pneumonia. Instead, she contracted Elizabethkingia, a bacterial infection. When Mrs. Cencula coded, a nursing assistant misread her patient file, believing that a DNR was included among other documents. Believing Mrs. Cencula was DNR, the nursing assistant did not notify other staff or call a code (which would alert a designated medical team that resuscitation measures were urgently needed). Instead, the nursing assistant did nothing for 30 minutes. When a staff member finally realized the mistake, the facility called 911, but Mrs. Cencula had already passed.

The Illinois Department of Public Health has already investigated Mrs. Cencula’s death and cited and fined Warren Barr North Shore of Highland Park.


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