Failure to Verify Code Status Leads to Unmet Resident Wishes
Summary
Licensed nurses at the facility failed to adhere to the policy and procedure for verifying code status in an emergency situation for a resident who was receiving hospice care. The resident, who had a history of severe cognitive impairment and was on hospice care, had a documented Full Code status, which was not honored when she was found unresponsive. The failure to verify the resident's code status led to the omission of life-saving measures, as the staff assumed she was a Do Not Resuscitate (DNR) due to her hospice status. On the evening of the incident, the resident was found unresponsive in her bed by RN A, who did not verify the resident's code status and failed to initiate cardiopulmonary resuscitation (CPR) as per the resident's wishes. RN A, along with RN C, provided postmortem care without calling a Code Blue or contacting emergency medical services. RN A later acknowledged that she was unaware of the resident's Full Code status and admitted that she did not check the resident's chart, which would have indicated the need for resuscitative measures. The RN Supervisor B, who was informed of the resident's passing, also assumed the resident was a DNR due to her hospice care and did not verify the code status. This assumption was incorrect, as the resident's husband had confirmed her desire to be a Full Code. The facility's failure to ensure staff followed procedures related to honoring an advance directive resulted in Immediate Jeopardy, as it placed all residents receiving hospice care at risk of not having their wishes honored.
Plan Of Correction
Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both federal and State laws. 1. Resident #1 expired on Nurse A and Nurse B were suspended immediately. 2. Residents who , in house in the past 3 months were reviewed to ensure all advanced directives were followed. This was completed by and no discrepancies were noted. All Code statuses were followed as ordered. Social services validated all current residents code status and validated the status is correct according to their individual wishes on Nurse A is no longer employed at the facility and the results of the investigation were reported to the board of nursing. Education was provided to Nurse B prior returning to work. 3. Facility completed code blue drills each shift 72 hours post incident and re-educated staff on our code blue policies. Completed by Staff received an electronic communication with immediate education on resident rights, advanced directives, and validating residents code status in their chart prior to calling a code blue on The nursing supervisors were re-educated by the ADON and/or designee by regarding verifying code status on any resident found without vital signs or unresponsive prior to having contact with residents. Licensed nurses have been in serviced by the ADON and/or designee by that residents receiving hospice service does not equate to the resident being a and staff must check all residents code status when they are found unresponsive. This was completed prior to having contact with residents. A new process was put into place where the Facility will add residents full code status order to the MAR to be signed off every shift by the nurse if the patient is on hospice and is a full code to increase visibility to nursing staff on. Written Code blue competency tests were administered to the licensed staff and CNAs and validated by the DON/Designee. Regularly scheduled staff completed by and PRN staff will complete testing prior to having contact with residents. Any new staff members will receive code blue education and competency testing during their orientation days before working the floor alone ongoing. Facility staff were re-educated by the ADON and/or designee of the advance directive processes; neglect and; resident's rights regarding treatment and advance directives; communication of code status; and physician notification of changes. Regularly scheduled staff completed by and PRN staff will complete education prior to having contact with residents. 4. Facility completed ad hoc QAPI on and continued with ad hoc QAPI for the following three weeks on and Code blue drills varying day/shift will continue weekly for one month, followed by three drills a month varying day/shift monthly thereafter to be completed by DON/designee. Random weekly checks will be completed by DON and/or designee for three months to ensure the nurses & CNAs are competent with checking the residents code status when a resident is found unresponsive, regardless of status, ie Hospice, STR, etc. ADON and/or designee will complete Weekly audits of current hospice residents to ensure there is a separate order being signed off stating the resident full code status if appropriate. Audits will be completed weekly for one month, followed by monthly for two months. DON and/or Designee will audit any new hires to ensure a code blue competency test has been satisfactorily completed monthly x3 months. Incident was reviewed during QAPI meeting on and committee agrees with this corrective action. Results of the previously mentioned audits including checking the code status, code blue drills, auditing of hospice resident orders, physician notification of change of condition for full code hospice residents and new hire competencies will be submitted to the Administrator and brought to QAPI for review and evaluation monthly. Audits will continue for a minimum of 3 months or until significant compliance has been met as deemed by the QAPI committee.
Removal Plan
- Administrator and DON initiated an investigation into discrepancies in resident #1's chart regarding her passing.
- The facility completed an in-house audit for code status of all residents.
- Licensed nurses were educated on the facility's policy and procedure for verifying code status prior to initiating or withholding lifesaving procedures including Code Blue drills to validate comprehension.
- Resident #1's husband was notified regarding discrepancies found and investigation.
- Law enforcement and elderly affairs were notified out of abundance of caution. An immediate report was filed with the state agency.
- A record review of resident #1 was completed by the DON.
- Social Service Director completed an audit of all current residents' code status.
- RN Supervisor B and RN A received personal training from the DON on checking residents' code status and starting Code Blue procedures. Both nurses were suspended pending investigation.
- Nursing Supervisors received individual education on checking code status when residents were unresponsive and initiating Code Blue procedures from the DON.
- A text was sent to all nursing staff containing education regarding if a resident was found unresponsive, it was the responsibility of the nurse to verify code status in the chart and initiate if Full Code.
- 64 of 81 total licensed nurses received education.
- 48 out of 81 nurses completed the education.
- An additional 10 of 81 nurses completed their education.
- An additional 6 of 81 nurses completed their education.
- Remaining licensed nurses would receive education prior to working next shift.
- New hire nurses at the facility would receive the above education during orientation and prior to working an assignment.
- Mock Code Blue drills were conducted to validate education received was retained.
- Starting weekly code blue drills to be conducted on varying shifts and days to include all shifts.
- Random weekly audits to be completed to ensure staff follow facility procedure for verifying residents' code status prior to initiating or withholding.
- New hire nurses at the facility to participate in a mock code drill during orientation and prior to working an assignment.
- Ad Hoc Quality Assurance and Performance Improvement (QAPI) held to review the recommendations made from the investigation. The QAPI committee reviewed education in progress and code blue drills.
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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