Failure to Provide Immediate CPR to Unresponsive Resident
Summary
The facility failed to provide immediate cardiopulmonary resuscitation (CPR) to a resident who was a full code when found unresponsive. The resident, who had diagnoses including paranoid schizophrenia, bipolar disorder, and obesity, was discovered unresponsive in their room by a Certified Nursing Assistant (CNA). Despite being CPR certified, the CNA did not initiate CPR, instead leaving the room to inform a Licensed Psychiatric Technician (LPT). The LPT, upon entering the room and finding the resident unresponsive, also did not start CPR immediately but instead sought assistance from a Licensed Vocational Nurse (LVN). The delay in initiating CPR was further compounded when the LVN, upon arrival, also failed to start CPR immediately. It was not until the Director of Staff Development (DSD) entered the room and instructed the LPT and LVN to begin CPR that the procedure was started. By this time, several minutes had passed since the resident was first found unresponsive. The emergency medical technicians (EMTs) arrived shortly after and took over the resuscitation efforts, but the resident was pronounced dead shortly thereafter. The facility's policy required that CPR be administered immediately to any resident found unresponsive unless there was an advance directive stating otherwise. In this case, the resident did not have an advance directive, and the facility's default policy was to treat all residents as full code. The failure to adhere to this policy and the delay in providing CPR were identified as deficiencies by the California Department of Public Health, which noted that the facility's noncompliance had caused or was likely to cause serious harm or death to the resident.
Removal Plan
- The Director of Nursing and Administrator provided in-service education to all nursing staff on duty, focusing on the protocol for providing CPR to an unresponsive resident.
- In-service training included: Nursing staff first on scene of the unresponsive resident will begin to administer CPR while calling for a Code Blue and the location of the resident.
- Staff not administering CPR will call 911 immediately.
- Nursing staff first on scene will not discontinue CPR until another nursing staff member that is CPR certified takes over doing CPR or paramedics arrive; whichever is first.
- Staff is not to leave the unresponsive resident until expiration has been verified by paramedics.
- The Director of Nursing reviewed all current residents' code status and documentation of no advanced directive by responsible party was all residents' charts. All current residents are full code status.
- The facility updated its Emergency Response Policy to clearly state that any staff member who discovered an unresponsive resident must immediately alert the nearest nursing staff and remain with the resident.
- The Director of Nursing conducted in-service training to licensed staff, nursing aid, and CNAs. The staff not present will be in-serviced immediately upon return to the facility.
- Code Blue Drills will be conducted randomly by the Director of Nursing on various shifts to ensure proficient and competent knowledge of Emergency Response Procedures.
- The Staff Developer will conduct audits of staff (across all departments when applicable) to assess knowledge of emergency response procedures and CPR protocol.
- Emergency Response Procedures will be a part of orientation training for all new nursing staff.
- The Quality Assurance Nurse will review all emergency response incidents for proper adherence to protocol.
- The Staff Developer will report the monitoring plan results during the Quality Assurance and Assessment meeting. The Quality Assurance and Assessment committee will review the effectiveness of the interventions and make any necessary adjustments to the plan. Monitoring will be on an ongoing basis until sustained compliance is achieved, as evidenced by compliance in all audits and drills.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to maintain accurate and complete crash cart audits for multiple full-code residents. Surveyors, accompanied by the DON, found that daily crash cart checks did not include verification of supply expiration dates, and that an extension cord documented as present on several audit dates was not actually in the cart. Audit logs also conflicted with the cart’s contents by indicating that required items such as eye protection, saline, and clear plastic were present when they were not. These findings were inconsistent with the facility’s policy requiring the crash cart to be checked every 24 hours and after each use, with prompt replacement of equipment and supplies.
Surveyors found that several nurses lacked proper CPR certification required to support residents with full code status. Some LPNs and an RN had no CPR certification documented in their personnel files, while other LPNs held CPR cards that, although covering adult, child, infant, and AED use, did not specify BLS or healthcare provider-level training. The DON confirmed these gaps, which were inconsistent with facility policies requiring verification of necessary licenses and certifications at hire and ongoing BLS CPR certification for key clinical staff involved in resuscitative efforts.
Surveyors found that the AED on the Rehab Hall crash cart had no pads attached and no pads stored in the AED compartments or in the crash cart, despite daily checks being documented on a crash cart checklist that did not include verification of AED function or pad availability. During the observation, the ADON confirmed that no AED pads were readily available. The facility reported that this crash cart and AED would be used in an emergency for 18 of 19 residents on the Rehab Hall who were identified as Full Code.
Three staff members, including a CNA, an RN, and an LPN, were found to be working without current CPR certification, as confirmed by personnel file reviews and staff interviews. The DON was aware of some expired certifications, and all three staff continued to work shifts despite the facility's policy requiring current CPR certification.
A resident with multiple serious medical conditions and a full code status was found unresponsive and exhibiting signs of death. Staff failed to immediately initiate CPR, with delays caused by uncertainty, lack of certification, and panic. When CPR was started, it was performed ineffectively and without proper equipment or technique, as confirmed by EMS upon arrival. Facility policy requiring immediate CPR for full code residents was not followed.
A resident with complex medical conditions had a signed Advance Directives Form indicating DNR CC-A, but the physician order listed the resident as full code for two months before being corrected. The DON confirmed the mismatch between the resident's documented wishes and the code status order, contrary to facility policy.
Inaccurate Crash Cart Audits and Missing Emergency Equipment
Penalty
Summary
The facility failed to ensure accurate and complete crash cart audits for residents requiring basic life support, affecting eighteen of thirty-five residents who were designated as full code. During an observation of the crash cart with the DON, surveyors found that the daily audit documentation for the month did not include verification of expiration dates for crash cart supplies. Review of the crash cart audit logs showed that an extension cord was documented as being in the cart on multiple dates, but the extension cord was not present in the cart at the time of inspection. Additionally, the audit documentation indicated that required items, including eye protection, saline, and clear plastic, were not present in the crash cart, yet they were documented as being in the cart. The facility’s undated “Emergency Crash Cart” policy stated that the crash cart is to be checked every 24 hours and after every use, and that equipment and supplies are to be noted and replaced promptly, but the observed documentation and contents of the cart did not match these requirements. This deficiency was verified with the DON at the time of the survey and was cited under the requirement that personnel provide basic life support, including CPR, to residents requiring emergency care, subject to physician orders and advance directives, and was investigated under Complaint Number 2687380.
Plan Of Correction
Cridersville Care Center Provider Number:366171 Survey Type: Complaint Survey Survey Date: 04/29/26 This Plan of Correction (PoC) outlines the actions completed by the facility with regards to the deficiency citation. This Plan of correction does not constitute any admission of guilt or liability by the facility and is submitted only in response to the regulatory requirements. Please accept the following as the facility's credible allegation of compliance as of 4/30/26. F678 CPR All Full Code residents #18 have the potential to be affected by the alleged deficiency. On 4/27/26 the DON/ADON re-stocked the crash cart per the inventory sheet for all missing items. Crash cart inventory sheet updated and new one will go into effect on 5/1/26. All licensed nursing staff provided with training related to crash cart inventory being a daily audit review using inventory sheet on 4/27/26 per DON/designee. The DON/designee will conduct clinical rounds and conduct a random audit of crash cart three times per week for 4 (four) weeks to ensure compliance. The results of the audit will be documented. The facility conducted an Ad-Hoc QAPI meeting on 4/27/26 and discussed the alleged deficiency and corrective actions. Date when corrective action will be completed: 4/30/26
Failure to Ensure Nursing Staff Held Proper BLS CPR Certification
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff held appropriate and current Cardiopulmonary Resuscitation (CPR) certification consistent with facility policy and the needs of residents who had elected full code status. Surveyors reviewed personnel records and found that multiple nurses, including several LPNs and an RN, either had no CPR certification on file or held CPR cards that did not specify Basic Life Support (BLS) or healthcare provider-level training. Specifically, LPNs with certain hire dates had no CPR certification in their files, and an RN also lacked any documented CPR certification. Other LPNs possessed CPR cards that covered adult, child, infant, and AED use, but the cards did not indicate that the training was BLS or designated for healthcare providers. The Director of Nursing confirmed during interview that several identified staff members had no current CPR certification on file and that others had CPR certifications that did not include BLS or healthcare provider designation. Facility policy on Licensure, Certification, and Registration of Personnel required staff who need a license or certification to present verification to Human Resources prior to or upon employment. Another policy on Emergency Procedure Cardiopulmonary Resuscitation required key clinical staff, including non-licensed personnel who would direct resuscitative efforts, to obtain and maintain American Red Cross or American Heart Association certification in BLS CPR. These findings affected residents who had chosen full code status, as the facility did not ensure that staff responsible for providing resuscitation met the specified CPR certification requirements.
AED on Rehab Hall Crash Cart Lacked Pads for Full Code Residents
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure an Automated External Defibrillator (AED) was ready for use for residents requiring basic life support, including CPR, prior to the arrival of emergency medical personnel. During an observation of the Rehab Hall crash cart with the ADON, the AED was found lying on top of the crash cart with no pads connected, and no pads were located in the AED compartments or in the crash cart. The crash cart had a daily checklist of items, all of which were marked as checked, but there was no checkbox to verify the AED’s working order or the presence of pads. In an interview at the time of the observation, the ADON confirmed that no AED pads were readily available. The facility reported that 18 of the 19 residents on the Rehab Hall were designated as Full Code and that this crash cart and AED would be used in the event of an emergency or code situation. This deficiency was investigated under Complaint Number 2725566. No additional resident-specific medical histories or conditions at the time of the deficiency were provided beyond the facility’s identification of 18 Full Code residents on the Rehab Hall.
Failure to Maintain Current CPR Certification Among Nursing Staff
Penalty
Summary
The facility failed to ensure that three out of five sampled staff members, including a CNA, an RN, and an LPN, maintained current certification in Cardio-Pulmonary Resuscitation (CPR). Personnel file reviews revealed that these staff members' CPR certifications had expired, and interviews confirmed that they were not currently certified. Despite this, all three staff members continued to be scheduled and actively worked shifts throughout the facility. The Director of Nursing (DON) acknowledged awareness of the expired certifications for the CNA and RN but was not aware of the expiration date for the LPN. Facility policy required staff to be properly trained and/or certified in CPR to provide basic life support until emergency medical services arrived, and to maintain current CPR certification. The deficiency was identified through review of personnel files, staff interviews, and facility policy, and was investigated under a specific complaint number.
Failure to Initiate Immediate and Effective CPR for Full Code Resident
Penalty
Summary
A deficiency occurred when staff failed to initiate immediate and appropriate cardiopulmonary resuscitation (CPR) for a resident with a full code status who was found unresponsive. The resident, an elderly male with multiple significant diagnoses including end stage renal disease, dementia, severe sepsis, and metabolic encephalopathy, was noted to be dependent on staff for all activities of daily living and had severely impaired cognition. On the evening in question, the resident was last observed in the dining room and later found unresponsive, cold to the touch, with blue fingertips and signs of rigidity by two certified nursing assistants (CNAs). Upon discovering the resident's condition, the CNAs sought assistance from a registered nurse (RN), who appeared panicked and did not immediately initiate CPR. The RN left the room to verify the resident's code status and retrieve the crash cart, during which time no resuscitative efforts were started. When additional nursing staff arrived, chest compressions were eventually initiated, but not until several minutes had passed. The staff performing CPR were not all currently certified, and the compressions were described as ineffective by emergency medical services (EMS) personnel upon their arrival. No airway management or use of an automated external defibrillator (AED) was observed, and the resident was not placed on a hard surface for compressions. EMS personnel noted that the resident exhibited signs of rigor mortis and had likely been deceased for several hours prior to their arrival, despite staff statements regarding the last time the resident was seen alive. Facility policy required immediate initiation of CPR for residents with full code status, but this was not followed. The incident affected one resident directly, with the facility identifying 178 residents with full code status at the time of the survey.
Failure to Ensure Code Status Orders Match Advance Directives
Penalty
Summary
The facility failed to ensure that a resident's code status orders accurately reflected their wishes as documented in their Advance Directives Form. Specifically, a cognitively intact resident with multiple complex medical diagnoses, including chronic kidney disease, heart disease, and diabetes, had a signed Advance Directives Form indicating a preference for Do Not Resuscitate Comfort Care-Arrest (DNR CC-A). Despite this, the physician order in the medical record listed the resident as full code from the time of admission until two months later, at which point the order was changed to DNR CC-A. This discrepancy was confirmed through medical record review and interview with the Director of Nursing, who acknowledged that the resident's code status order did not match the documented advance directive for a significant period. The facility's policy requires that advance directives be respected and that the plan of care be consistent with the resident's documented treatment preferences, but this was not followed in this case.
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