Failure to Provide CPR Due to Incorrect Code Status
Summary
The facility failed to provide basic life support, including CPR, to a resident as per the resident's advance directives. The resident was found unresponsive and without a pulse, but the facility staff inaccurately identified the resident's code status as Do Not Resuscitate Comfort Care Arrest (DNRCC-A) based on an internal report sheet. This error occurred despite the resident's medical record indicating she was a full code, as per her advance directives upon admission. Consequently, CPR was not initiated, and Emergency Medical Services (EMS) were not called until approximately an hour and fifteen minutes after the resident was found unresponsive. The resident, who had a history of sepsis, urinary tract infection, pressure ulcer, chronic obstructive pulmonary disease (COPD), acute congestive heart failure (CHF), diabetes, atrial fibrillation, hypertension, history of pulmonary embolism, and malignant neoplasm of the endometrium, was admitted to the facility with a full code status. On the night of the incident, the resident was found unresponsive in her bed by a State Tested Nursing Assistant (STNA), who then called for nursing assistance. Two nurses verified the absence of vital signs but relied on an incorrect report sheet that listed the resident as DNRCC-A, leading to a delay in initiating CPR. The error was discovered later when a Licensed Practical Nurse (LPN) reviewed the resident's electronic medical record for next of kin information and found the correct full code status. The Director of Nursing (DON) was notified, and CPR was initiated, but it was too late to prevent the resident's death. The facility's failure to verify the resident's code status in the electronic medical record and reliance on an inaccurate report sheet were critical factors that led to the deficiency.
Removal Plan
- Licensed Practical Nurse (LPN) #150 was reviewing Resident #44's electronic medical record to obtain next of kin information and funeral home preference when she discovered Resident #44's code status was a full code. The DON was notified, and a directive was given to initiate CPR and to call 911. CPR was initiated and EMS were called.
- Resident #44 was transported out of facility via EMS.
- One Registered Nurse (RN), two LPNs, two State tested Nursing Assistants (STNAs) on site were re-educated by the DON on timely delivery of services and care, change of condition, and notification, and where to find code status orders (in Point Click Care (PCC)). RN #100 (the staff member identified to be responsible for the error in not initiating CPR timely) was suspended pending investigation.
- All staff re-education was initiated related to change in condition, timely delivery of care and services, documentation, where to find code status orders (in PCC), and notification by the DON, ADON, and Regional Quality Assurance Registered Nurse via in person or telephone. Staff trained included five RNs, nine LPNs, 19 STNAs, three housekeeping staff, three dietary staff, and one activity personnel.
- The Social Service Designee attempted to contact Resident #44's family without success. A voicemail was left. The Social Services Designee and preceptor began an audit of all 43 resident's advance directives' orders and advance directives on file in chart. Each was verified and cross-referenced for accuracy. Any identified findings were corrected upon discovery.
- The Human Resource Director verified CPR certification of RN #100 and LPN #150 and began audits of all licensed nurses (five RNs and nine LPNs) CPR certifications. Any identified findings were addressed immediately.
- All current report sheets were removed from the facility and replaced with new report sheets that did not include the resident's code status by Regional Director of Quality Assurance RN.
- The facility Medical Director was notified by the DON of the incident involving Resident #44 and the delay in CPR initiation and current process of correction.
- All staff on shift interviews were completed with RN #100, LPN #150, STNA #175, and STNA #200, who were all of the staff on duty when Resident #44 was found unresponsive and without an obtainable pulse. Re-education was provided related to change in condition, timely delivery of care and services, documentation, where to find code status orders (in PCC), and notification by the Regional Director of Quality Assurance RN.
- All licensed nurses not CPR certified (two RNs and three LPNs) were removed from direct patient care by the Administrator and not utilized in the role as a licensed nurse until their CPR certification was current.
- All staff re-education (which included five RNs, nine LPNs, 19 STNAs, three housekeeping staff, three dietary staff, and one activity personnel) was completed by the DON, ADON, and Regional QA nurse related to change in condition, timely delivery of care and services, documentation, where to find code status orders (in PCC), and notification.
- The advance directives/code status for all 43 facility residents was verified and cross-referenced, orders in PCC verified, and audit completed by Social Services Designee.
- A crash cart (cart with emergency supplies/equipment) audit was completed by the DON to ensure all required supplies were present on the cart and the cart was replenished.
- All licensed nurses (five RNs and nine LPNs) CPR certifications were current and valid. An Ad hoc Quality Assurance (QA) meeting was held. The facility implemented a plan for all licensed nursing staff CPR certifications to be verified upon hire, annually, and evaluated during annual performance evaluations.
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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