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:
A resident with intact cognition, multiple medical diagnoses, and documented full code status was found unresponsive, pulseless, and nonbreathing while receiving care. An RN believed Hospice enrollment changed the code status to DNR and did not start CPR or call a code blue, despite the resident’s full code order being documented in the chart.
A resident with respiratory failure and COPD, whose advance directives and orders indicated Full Code, was found unresponsive by an RN. The RN checked for a pulse, confirmed the resident was gone, but did not start CPR or call EMS; another nurse also assessed the resident, and the resident was pronounced dead shortly after. Family members and the DON stated CPR was not initiated despite the resident’s Full Code status.
A resident with a documented DNRCCA order had CPR started during a respiratory emergency before the code status was verified, despite staff records showing the resident was DNRCCA and cognitively impaired. Staff reports described confusion during the event, with CPR initiated while family members were present and code status confirmation occurring after compressions had already begun. In a separate record review, another resident’s chart showed DNRCCA in the EMR and care plan, but the hard chart lacked signed code status documentation.
Ambu Bag Not Readily Available During Code Blue: A Full Code resident was found unresponsive and not breathing, and staff began CPR during a Code Blue, but an ambu bag was not readily available at the start of the event. Staff used a non-rebreather mask while looking for the ambu bag, and interviews confirmed the device was not in use when the code began. The DON stated an ambu bag is part of the expected emergency equipment and that a non-rebreather mask does not replace it.
A resident with full code status became unresponsive and staff began chest compressions, but an LPN did not immediately call 911 and CPR was performed without ventilations or rescue breathing. EMS arrived to find staff doing compressions only and documented that the resident had been without ventilations for more than 12 minutes before EMS initiated BVM ventilations and continued resuscitation efforts.
RN 2 did not maintain CPR/BLS certification from a provider that included the required hands-on skills component. File review showed the certification came from an online provider, and RN 2 stated the course was entirely online with reading, videos, and questions only, with no CPR skills demonstration. The DSD confirmed the certification needed hands-on validation under the facility CPR policy.
Failure to Provide CPR for Full Code Resident
Penalty
Summary
Facility staff failed to provide basic life support, including CPR, for a resident who was found pulseless and nonbreathing. The resident had diagnoses including peritoneal abscess, type 2 diabetes, and severe protein-calorie malnutrition, and a quarterly MDS assessment indicated a BIMS score of 13 out of 15, showing intact cognition. The resident was their own decision maker and had a documented full code status signed and dated in the medical record. The resident was enrolled in Hospice services, and on the night of the incident, CNA-G and CNA-H were providing a bed bath while RN-E entered the room to complete a skin check and change a dressing on the resident’s buttocks. After the dressing change, the resident began having loose stools. RN-E left to get additional wound supplies while the CNAs continued care, and CNA-H thought the resident had passed away and left to notify RN-E. RN-E returned, found the resident unresponsive without observable respirations or signs of life, and believed the code status had changed to DNR when Hospice services began. RN-E did not initiate CPR or call a code blue, and instead asked LPN-F to inform Hospice of the resident’s passing. The investigation found that the resident’s code status was accurately documented in the medical record, physician orders, and care plan, and that RN-E was aware the resident was full code but failed to follow the resident’s documented wishes and the facility’s emergency response procedures.
Failure to Initiate CPR and Call EMS for Full Code Resident
Penalty
Summary
The facility failed to initiate CPR and call EMS for a resident who was found unresponsive and had Full Code status. The resident had been admitted from an acute care hospital and had diagnoses including acute and chronic respiratory failure with hypoxia and hypercapnia, as well as COPD. Advance directives, the order summary, and the MAR/TAR all identified the resident as Full Code, and a progress note documented that the resident wanted to remain Full Code. According to the record and staff interviews, the resident was last seen at about 4:45 AM when a breathing treatment was started. At about 5:50 AM, an RN entered the room to tell the resident the shift was ending, found no response, touched the resident, and checked for a radial pulse, which was absent. The RN then went to the hallway and alerted the incoming nurse that the resident was gone. The RN later checked the chart and confirmed Full Code status, but CPR was not started and EMS was not called. Another nurse was present and also assessed the resident, with absent apical pulse confirmed, and the resident was pronounced dead at 6:00 AM. Family members stated they were told the RN panicked and did not start CPR or call EMS. The DON confirmed that the resident was Full Code and that the RN who found the resident unresponsive did not initiate CPR or check code status right away. The facility policy stated that when a resident is found without heartbeat and respirations, the nurse on duty identifies code status and, if the resident is Full Code, CPR is started and 911 is activated.
Advance directives not honored during CPR event and code status documentation incomplete
Penalty
Summary
The facility failed to honor advance directives for a resident with a documented DNRCCA order when CPR was initiated during a respiratory emergency. Resident #91 was admitted with acute respiratory failure with hypoxia, pulmonary embolism, and tracheostomy status, and the record showed the resident was cognitively impaired, totally dependent for ADLs, and had a physician order and care plan identifying DNRCCA status. During the event, staff were alerted that the resident was having trouble breathing, and the respiratory therapist entered the room, found the resident not breathing, and began CPR before the code status was verified. According to the facility investigation and staff statements, multiple staff members responded to the room, the crash cart was brought in, and CPR continued while EMS was called. One witness stated the family was asked if they wanted life support and said yes, while another witness stated the resident’s spouse and son were present and that the spouse was removed from the room. The regional nurse confirmed CPR was initiated when it should not have been because the resident had a DNRCCA order. The DON stated staff believed someone was sent to verify the code status while the code continued, and the respiratory therapist stated she did not have time to look in the chart before starting compressions. The facility also failed to ensure advance directive documentation was accurate in the medical record for another resident. Resident #28 had physician orders and a care plan indicating DNRCCA, but the record did not contain signed documentation verifying that status in the hard chart. A review of the electronic chart showed DNRCCA, while the regional nurse stated there was no signed code status paper in the medical record and reported that the resident had said he wanted to be a full code. The facility policy required advance directives to be maintained in the medical record and readily retrievable, and to be followed.
Ambu Bag Not Readily Available During Code Blue
Penalty
Summary
The facility failed to ensure the immediate availability of essential emergency resuscitation equipment for a resident who was designated Full Code during a Code Blue event. When the resident was found unresponsive and not breathing, staff initiated CPR, but an ambu bag was not readily available at the start of the emergency. Staff instead used a non-rebreather mask, and one nurse asked for an ambu bag to be brought from another floor. The resident’s code was documented as having been initiated immediately, with CPR continuing until EMS arrived and took over. Interviews confirmed that staff observed the ambu bag was not in use and was not readily available when the code began. A nurse stated that chest compressions were being performed when he arrived, but there was no ambu bag in use. Another nurse said staff were looking for the ambu bag and that it was not readily available at the start of the code, though one was brought in before EMS arrival. The DON stated that staff were expected to respond immediately with all necessary equipment, including an ambu bag, oxygen, and an IV starter kit, and acknowledged that a non-rebreather mask does not replace an ambu bag. The crash cart stock list identified one ambu bag on top of the cart, and the facility’s CPR policy stated that emergency basic life support should be provided immediately, including CPR, in accordance with physician orders and advance directives.
Failure to Provide Ventilations During Code Response
Penalty
Summary
The facility failed to provide basic life support to a resident with full code status when the resident became unresponsive and was found without vital signs. The resident had Huntington's disease, dysphagia, anxiety, gastrostomy status, severe cognitive impairment, and was dependent on staff for all activities of daily living. The care plan and physician orders reflected full code status, with CPR to be initiated in the event of a cardiac or respiratory event. On the evening of the event, staff identified the resident as unresponsive after dinner. LPN #200 checked the resident, found no vital signs, and began chest compressions after checking code status and bringing the crash cart to the room. However, staff did not immediately call 911; the call was made only after compressions had already started. EMS records showed the 911 call was received at 8:06 P.M. and EMS arrived at 8:18 P.M. When EMS arrived, staff were performing chest compressions without ventilations. EMS documented that the resident had been without ventilations for greater than 12 minutes and then initiated ventilations with a bag valve mask while continuing resuscitation efforts. Interviews and record review showed that LPN #200 and LPN #216 performed chest compressions only and did not provide rescue breathing or ventilations during the code. LPN #200 stated the bag valve mask was not used because staff did not know how to use it and believed it was not on the crash cart, although the cart audit logs and observation showed bag valve masks and CPR mouth shields were present. The DON stated that if a code occurred, staff should call 911, apply the AED, and have one nurse provide ventilations while another performed compressions. EMS later pronounced the resident deceased after resuscitation efforts were stopped by physician direction.
RN lacked CPR certification with hands-on skills validation
Penalty
Summary
The facility failed to ensure that RN 2 maintained current CPR certification from a CPR provider whose training included a hands-on session in accordance with accepted national standards. During employee file review with the DSD, RN 2’s BLS certification was found to have been obtained from an online CPR provider, and the DSD stated she did not know whether the certification was entirely web based without the required in-person hands-on component. RN 2 later stated that the BLS course she completed was entirely online and consisted of reading materials, watching videos, and answering questions, with no hands-on component or requirement to demonstrate CPR skills. During a later interview, the DSD stated RN 2 needed to obtain BLS certification that included a hands-on component where skills are validated, and said this was necessary to ensure staff competency in performing CPR. Review of the facility’s CPR policy showed that staff were to maintain current CPR certifications through a provider whose training included a hands-on session in a physical or virtual instructor-led setting in accordance with accepted national standards, and that online knowledge components were acceptable only when in-person skills demonstration was also required.
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