Failure to Initiate Immediate CPR and Inadequate Emergency Cart Stocking
Summary
The facility failed to provide immediate CPR to a resident, identified as Resident 41, who was found unresponsive, without a pulse, and not breathing. The Licensed Vocational Nurse (LVN 1) delayed initiating CPR because they first checked the resident's code status and called for assistance instead of starting CPR immediately. This delay occurred despite the facility's policy and procedure, which required immediate CPR initiation in such situations unless a Do Not Resuscitate (DNR) order was present. Resident 41 had a full code status, meaning they wished to be revived if their heart stopped beating or they stopped breathing. The resident was admitted with diagnoses including congestive heart failure, acute respiratory failure with hypoxia, and chronic obstructive pulmonary disease. On the day of the incident, the resident was found unresponsive in bed by LVN 1, who then left the room to verify the resident's code status before starting CPR. This delay in initiating CPR was critical, as the resident was later transferred to a General Acute Care Hospital, where they were pronounced dead. Additionally, the facility's emergency cart was found to be inadequately stocked with essential items needed for CPR, such as an Ambu-bag, glucometer, and pulse oximeter. This lack of preparedness could have further contributed to the delay in providing life-saving measures. The facility's policy required that emergency carts be fully stocked and ready for use, but this was not adhered to, as evidenced by the missing items during the surveyor's inspection.
Removal Plan
- (DON) had a 1:1 in-service with the licensed nurse assigned to Resident 41 regarding Medical Emergency Response. Disciplinary action was taken with licensed nurse who delayed the CPR on the full code resident and was suspended pending investigation.
- The Medical Records Director (MRD) or designee completed a chart audit on every resident and compared the Advance Directive/Physician Orders for Life Sustaining Treatment (POLST) to the physician order for accuracy.
- The facility emergency cart checklist was revised by the DON. The glucometer, glucose strips, lancets, nebulizer, and nebulizer kit were added. The updated form will be utilized by licensed nurses. The emergency cart was checked by the DON for appropriate supplies and equipment. No issues were identified.
- The Resource Nurse Consultant (RNC) and Respiratory Therapy Consultant designee educated licensed nurses and certified nurse assistance (CNAs) on the facility's policy and procedure for Medical Emergency Response and location of code status for each resident. Licensed nurses and CNAs were not permitted to work a shift until education was completed. Nurses on leave will receive education prior to their next scheduled shift.
- The RNC and Respiratory Therapy Consultant initiated Code Blue drill to be completed on all shifts randomly by using the facility landline's paging system located at the nurse's station, hallway outside room, between rooms, activity room, rehabilitation room and office rooms (Administrator, DON, Dietary, SSD office), and announcing Code Blue to room. Licensed nurses and CNAs were in-serviced by the RNC regarding the paging system. The licensed nursing and CNAs staffs who were not scheduled to work will participate in the Code Blue drill during their scheduled shift.
- The RNC, (Director of Nursing) DON and (Director of Staff Development) DSD conducted an audit of licensed nurses and certified nurse assistants (CNAs) CPR certification. No issues were identified.
- Newly hired licensed nurses and CNAs will have their CPR certification card on file and have competency prior to their scheduled shift.
- DON or designee will audit new admissions chart to compare the resident's Advance Directives/ POLST to the physician orders for accuracy. This audit will continue for three months. Findings will be reviewed at the monthly QA (Quality Assurance) Committee meeting for discussion and recommendations.
- Licensed nurse will print the daily code status from PCC orders and will place it in the binder labeled Code Status located at the nurse's station. The SSD will oversee that the code status is available and updated daily. In the absence of SSD, the license nurse working will verify that the code status is updated.
- The POLST will be reviewed and verified by the DON and SSD immediately after admission of the resident to the facility. The RN Sup will oversee the POLST in the A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented.
- DON or designee to complete weekly mock code drills on all shifts and monitor code status compliance by interviewing licensed nurses about facility CPR policy and procedure, as well as requesting return demonstration of CPR process. Any trends will be discussed during monthly Quality Assurance meeting which will be held scheduled monthly. The DON will conduct compliance audits weekly for three months. Findings will be reported at monthly QA Committee meeting for discussion and recommendations.
- The DON will randomly audit the emergency cart on a weekly basis in addition to the daily checks from licensed nurse to ensure that the equipment and supplies are stocked as indicated on the emergency cart checklist. This audit will continue for three months. Findings will be reviewed at the monthly QAA (Quality Assurance) Committee meeting for discussion and recommendations.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to maintain documentation that 14 of 41 licensed nurses had current CPR certification for Healthcare Providers. CPR cards were not available for several RNs and LPNs, and the NHA and DON confirmed the facility did not ensure these nurses maintained current CPR certification in accordance with accepted national standards.
An agency CNA found a full code resident unresponsive, but an agency RN did not check for a pulse or vital signs and did not start CPR before leaving to call EMS and look for help. Staff present were not CPR certified, and EMS arrived to find the resident pulseless and apneic with no CPR started by the facility. The resident later died at the hospital.
Facility staff failed to ensure that an LPN and a CNA maintained current CPR certification while working scheduled shifts. Interviews with the Administrator, DON, and HR Director confirmed that RNs, LPNs, and CNAs were expected to hold active CPR cards, and record review showed the LPN’s CPR had expired before renewal while the CNA could not produce a valid CPR card for the employee file. Staffing schedules showed both employees worked multiple shifts despite the lapse, and the job descriptions for both roles required current CPR certification.
A full-code resident with atrial fibrillation, liver cirrhosis, and osteomyelitis was found unresponsive after a family member alerted staff to breathing trouble. Staff entered the room without emergency equipment, and CPR was not started promptly; records and interviews showed delays in recognizing the emergency, calling Code Blue/911, and bringing in the AED, AMBU bag, and crash cart. The resident later expired, and the death certificate listed myocardial infarction as the cause of death.
LPNs and RNs did not maintain current CPR certification for Healthcare Providers with a required hands-on component. Facility policy required active CPR certification for licensed nurses, but review of certification cards showed that 16 of 33 licensed nurses had only online-only CPR training for non-healthcare providers. The HR Director, NHA, and DON confirmed the deficiency.
A resident with CHF was found unresponsive and CPR was performed even though the chart contained an active DNR order, an MDS indicating DNR, and a POLST choosing DNR and allowing natural death. LN stated she reviewed the physician order at the time and confirmed the resident was DNR, and the DON confirmed the resident's orders and POLST indicated DNR.
Missing Current CPR Certification for Licensed Nurses
Penalty
Summary
The facility failed to maintain documentation that its nursing personnel had current education and certification to provide basic life support, including CPR, prior to the arrival of emergency medical personnel and subject to physician orders and residents’ advance directives. A review of the facility’s CPR policy showed it was intended to ensure timely and appropriate initiation of CPR by licensed nursing staff in accordance with facility policy, resident rights, and federal and state regulations. During the survey, the facility provided a list of 41 currently employed licensed nurses and copies of CPR certification cards for review. CPR certification cards were not available for RN Employees E3, E4, E5, E6, and E7 and LPN Employees E8 through E16, totaling 14 of 41 licensed nurses. In an interview, the Nursing Home Administrator and the DON confirmed that the facility failed to ensure these nursing personnel maintained current CPR certification for Healthcare Providers through a CPR provider whose training included a hands-on session in a physical or virtual instructor-led setting in accordance with accepted national standards.
Failure to Start CPR for Full Code Resident
Penalty
Summary
The facility failed to assess a resident for a pulse or vital signs and failed to immediately start CPR for a resident who was a full code and was found unresponsive. Resident #60 had diagnoses including multiple fractured ribs on the left side, acute respiratory failure with hypoxia and hypercapnia, type 2 diabetes mellitus with diabetic peripheral angiopathy, CHF, PVD, osteoarthritis of the left knee, and atherosclerotic heart disease of the native coronary artery. The resident’s code status was documented as full code, and the care plan stated CPR should be started and EMS called if needed. According to the CCTV timeline and staff statements, an agency CNA found the resident unresponsive during rounds and summoned nursing staff. An agency RN arrived at the room, briefly entered, and then left without taking vital signs, checking for a pulse, or starting CPR. The RN then went to the nurses’ station and made calls while the resident remained without CPR. Other agency CNAs were present, but they were not CPR certified. EMS arrived several minutes later and found the resident unresponsive, pulseless, and apneic, with no evidence that facility staff had started CPR before EMS arrival. The 911 audio, CAD log, EMS report, police report, and witness statements all reflected that the resident was found unresponsive and that the facility did not initiate CPR. The police officer reported staff were standing in the room and did not know what to do, and EMS reported the facility staff did not start CPR and did not know the approximate down time. The hospital record stated the resident had been found unresponsive by nursing facility staff, no CPR had been performed by the facility for over ten minutes, and EMS initiated CPR and ACLS during transport. The resident was later pronounced dead at the hospital.
Failure to Maintain Current CPR Certification for Nursing Staff
Penalty
Summary
The facility failed to ensure that a nurse and a CNA maintained current CPR certification while working in the facility. Surveyor interviews and record review showed that facility leadership and HR stated that RNs, LPNs, and CNAs were required to have active CPR certification, and that CPR was needed because staff would respond during a code until EMS arrived. Despite this, the surveyor was unable to obtain a current CPR certification card for a CNA after multiple requests to the Administrator, Assistant Administrator, and DON, and the HR Director stated that the CNA had not produced a valid CPR certification for the employee file. Record review also showed that an LPN had worked multiple night shifts while her CPR certification had expired. The LPN confirmed receiving an HR email about the expiration and stated she renewed her CPR certification on the day of the interview. The expired CPR certificate showed the prior certification had lapsed before the renewal date. The HR Director stated she had sent an email about the upcoming expiration but did not follow up after returning from medical leave. Daily staffing schedules showed that the LPN and CNA worked multiple shifts during the review period despite not having active CPR certification. The facility’s job descriptions for both LPNs and CNAs stated that current CPR certification was required. The facility census report showed 149 residents in the facility at the time of the survey.
Delayed CPR Initiation for Full-Code Resident
Penalty
Summary
The facility failed to initiate CPR in a timely manner for a resident who was full code and found unresponsive. The resident had diagnoses including atrial fibrillation, liver cirrhosis, and osteomyelitis of the right ankle and foot, and the MDS documented moderately impaired cognition. The medical orders, MOLST, and care plan all documented full code/CPR status. Surveillance video showed that after a family member alerted staff that the resident was unresponsive, RN #11 and PCT #5 entered the room without emergency equipment. RN #12, the Assistant DON, later entered the room without equipment, and no medical equipment was observed being brought to the room for several minutes. The video also showed multiple staff entering and exiting the room over time, with the AED, AMBU bag, cardiac board, and crash cart not brought in until much later. The Code Blue/CPR worksheet documented CPR as initiated at 7:01 PM, while other records and staff statements reflected delays and inconsistent times for when the resident was found, when CPR began, and when EMS was called. Staff interviews described that the resident was breathing slowly at first, then became unresponsive, with inability to obtain a pulse or blood pressure. PCTs stated they notified RN #11 after the family member reported trouble breathing, and one PCT stated RN #12 said the resident had already passed away before CPR began. RN #14 stated they responded to an overhead Code Blue and saw RN #12 performing CPR, while the DON later stated the facility’s investigation found CPR was not initiated until RN #13 entered the room. The resident expired at 7:22 PM, and the death certificate listed myocardial infarction as the cause of death.
LPNs and RNs Lacked Acceptable CPR Certification
Penalty
Summary
Facility nursing personnel did not maintain current CPR certification for Healthcare Providers through a CPR provider whose training included a hands-on session either in a physical or virtual instructor-led setting in accordance with accepted national standards for 16 of 33 licensed nurses. The affected staff included LPNs E1 through E12 and RNs E13 through E16. The facility policy titled Cardiopulmonary Resuscitation CPR stated that licensed nurses, respiratory therapists, and van drivers must hold active CPR certification for healthcare providers, and that online-only courses were not acceptable. Review of the CPR certification cards for the 16 licensed nurses showed that their certification was from an online-only CPR class for non-healthcare providers and did not include a hands-on session. During an interview, the Human Resources Director confirmed that these employees did not have the appropriate CPR certification for licensed nurses. The Nursing Home Administrator and the DON also confirmed that the facility failed to ensure that facility nursing personnel maintained current CPR certification for Healthcare Providers through a CPR provider whose training included a hands-on session either in a physical or virtual instructor-led setting.
CPR Performed Despite Active DNR Order
Penalty
Summary
The facility failed to confirm the code status of Resident 96 during an emergency when LN 3 performed CPR after the resident was found unresponsive. Resident 96 had been readmitted with a diagnosis of congestive heart failure, and the record showed an active physician order for DNR, along with an MDS assessment and POLST indicating DNR and allowing natural death to occur. During interview, LN 3 stated CPR was performed after Resident 96 was found unresponsive and that she reviewed the physician order at that time and confirmed the resident's code status was DNR. The MDS Coordinator confirmed the POLST and MDS assessment indicated DNR, and the DON confirmed the OSR showed an active DNR order and stated the physician's order and POLST were expected to be carried out correctly; otherwise, the resident's wishes were not honored.
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