Failure to Verify DNR Status Leads to Unwanted CPR
Summary
Licensed nurses at the facility failed to adhere to the policy and procedure for Cardiopulmonary Resuscitation (CPR) by not verifying the resuscitation or code status of a resident in an emergency situation. The incident involved a resident who was found unresponsive in his wheelchair at the nurse's station. Without verifying the resident's code status in the medical record, a licensed nurse initiated CPR. This action was contrary to the resident's documented wishes and a physician's order for Do Not Resuscitate (DNR). The resident, an elderly male with severe cognitive impairment and multiple medical conditions, had a documented DNR order signed by his wife and attending physician. Despite this, the electronic medical record (EMR) contained a conflicting physician order indicating Full Code status. The discrepancy arose because the Assistant Director of Nursing (ADON) failed to update the EMR with the correct DNR status after a care plan meeting where the resident's wife signed the DNR order. Consequently, when the resident was found unresponsive, the staff relied on the outdated EMR information, leading to the initiation of unwanted resuscitation efforts. The failure to verify the resident's code status before initiating CPR resulted in the resident undergoing aggressive resuscitation efforts, which were against his and his family's wishes. The incident highlighted a breakdown in communication and procedure adherence among the nursing staff, as multiple staff members assumed the code status had been verified by others. This oversight placed the resident at risk for unwanted medical intervention and prolonged suffering, ultimately leading to his transfer to the hospital where he was intubated against his wife's wishes.
Removal Plan
- Current licensed nurses were educated on facility's CPR policy and on procedure for performing a code to include confirmation of resident code status prior to initiating CPR. Post test and code procedure competencies completed to validate comprehension.
- 39 of 41 total licensed nurses received education; 95% of nurses: 10 out of 41 nurses completed the education, 24% of nurses, an additional 29 of 41 nurses completed their education, 71% of nurses.
- 2 remaining licensed nurse to receive education upon return from leave and prior to working next shift.
- New hire nurses at the facility will receive the above education during orientation and prior to working an assignment.
- Current licensed nurses participated in Mock Code Drills: 18 of 41 total licensed nurses participated in mock code drills; 44% of nurses 11 out of 41 nurses participated in mock code drills, 27% of nurses, 7 out of 41 nurses participated in mock code drills, 17%.
- 23 remaining licensed nurses to participate in mock code drills upon return from leave and prior to working next shift.
- New hire nurses at the facility will participate in a mock code drill during orientation and prior to working an assignment.
- Ad Hoc QAPI completed with Medical Director, Administrator, Director of Nursing and additional IDT members on the adherence to CPR policy and checking the residents code status prior to initiating CPR.
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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