Failure to Adhere to DNR Order and CPR Certification Lapse
Summary
The facility failed to ensure that a licensed nurse, who was not certified to perform cardiopulmonary resuscitation (CPR), did not perform CPR on a resident with a do not resuscitate (DNR) code status. This incident involved a resident with a medical history of type 2 diabetes mellitus, dysphagia following cerebral infarction, dementia, asthma, acute ischemic heart disease, atherosclerotic heart disease, and hypertensive chronic kidney disease. The resident's Physician Orders for Life-Sustaining Treatment (POLST) clearly indicated a DNR status, which was not adhered to by the staff. During the event, Registered Nurse (RN) #8, whose CPR certification had expired, initiated CPR on the resident despite the DNR order, after the resident was found unresponsive and not breathing. RN #8 stated that she felt compelled to act based on the family's wishes, despite the resident's documented DNR status. The Director of Staff Development acknowledged that there was no guarantee of having a CPR-certified staff member on each shift, and the Director of Nursing expected all licensed nurses to maintain CPR certification and adhere to residents' POLST in emergencies.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with acute respiratory failure and heart failure had a documented Full Code status and a POLST specifying Attempt Resuscitation/CPR and Full Treatment. During night rounds, two CNAs found the resident not breathing, cool to the touch, with yellow skin and no pulse, but did not initiate CPR or call a code blue, instead going to notify an LPN. The LPN assessed the resident, confirmed absence of vital signs, noted the body was cold with mottling and no rigor mortis, and contacted the DNS, physician, and 911 for the coroner’s number, but did not start CPR or activate a code blue. No lifesaving measures were attempted despite facility policy requiring CPR for unresponsive residents without a valid DNR and the resident’s clearly documented full code status, leading surveyors to cite Immediate Jeopardy and substandard quality of care.
A resident with multiple cardiac and respiratory comorbidities, documented as cognitively intact and designated as full code by physician orders, POLST, and care plan, was found unresponsive without pulse or respirations by a CNA, who notified an LPN. The LPN, who later admitted he did not follow protocol and had not checked the medical record, assumed the resident was a no code based on appearance, told the CNA the resident was DNR, and did not initiate CPR. A second LPN was called to verify death, questioned whether CPR was needed, confirmed absence of heart sounds and respirations, but also did not start CPR; only later did this nurse review the chart, confirm the full-code status, and report the issue. The physician, DON, and Administrator all stated they would have expected CPR to be initiated in accordance with the resident’s documented wishes and facility CPR policy.
A resident with multiple chronic conditions and a clearly documented full code status was found unresponsive, pulseless, and not breathing. Staff policy and American Heart Association guidelines required immediate, continuous CPR until advanced medical providers arrived, but video review and interviews showed that no CPR equipment was brought to the room and no continuous CPR was provided. An LPN assumed the resident was DNR because hospice services were in place and did not verify code status, while another LPN acknowledged not initiating CPR until instructed by the DON. The hospice nurse arrived to find the resident covered with no life-saving measures in progress, despite existing orders for full code, and the facility could not produce evidence that the resident’s code status was promptly verified or that CPR was continuously performed.
A resident with significant cardiac history and a POLST indicating full code status became weak, developed shallow breathing, stopped talking, and became unresponsive after dinner. CNAs summoned nursing staff, but the RN focused on obtaining vital signs and verifying code status, left the resident sitting upright, and did not initiate CPR, citing a pain response as evidence of responsiveness. An LVN recognized abnormal breathing and the need to call 911 but did not start CPR, and another LVN was unaware that ventilation should be provided to an unresponsive resident with slow breathing; no staff performed chest compressions before EMS arrival. The crash cart contained only 8 L/min oxygen regulators, preventing proper BVM use at 15 L/min, and the RN could not determine that the oxygen tank was empty or correctly connect the suction machine. EMS arrived to find the resident pulseless, apneic, in asystole, and with no CPR in progress, leading surveyors to cite a deficiency for failure to provide immediate, effective BLS and CPR to a full-code resident.
A resident with multiple chronic conditions and recent COVID-19 illness, who was clearly documented as full code, was found unresponsive and not breathing by a CNA, who notified an LPN. The LPN confirmed full code status, initiated chest compressions, and called 911 while the CNA assisted. When EMS arrived, staff were performing compressions and attempting ventilation with a BVM that lacked a mask and was not connected to O2, contrary to facility policy requiring use of a face mask or resuscitator bag to provide effective breaths. EMS noted the improper BVM setup, that compressions were stopped during the handoff, and that the resident was cold with rigor mortis present, indicating the facility failed to perform CPR in a manner that provided adequate oxygenation.
A resident with cardiac and pulmonary conditions, initially defaulted to full code status, later completed a physician-signed DNR order that was placed in an admission folder but not communicated to nursing or entered into the EMR. The Admissions Director did not forward the DNR paperwork to the SSD or DON, and the SSD created the resident’s profile as full code, leaving the hard chart, EMR, and door sticker system all reflecting full code. When the resident was found unresponsive, staff and EMS initiated and continued CPR based on the incorrect full code information, and only afterward did the SSD discover the signed DNR form in the admission packet.
Failure to Initiate CPR for a Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide CPR in accordance with a resident’s documented full code status. The facility’s Emergency Procedure CPR policy, initiated in 2001, required staff trained in CPR to initiate resuscitation on unresponsive residents who were not breathing unless there was a valid DNR order or clear signs of irreversible death such as rigor mortis. The policy further specified that if a resident’s DNR status was unclear, CPR should be started and continued until a DNR was confirmed. Resident 3 had been admitted with diagnoses including acute respiratory failure and heart failure and had a care plan and POLST on file indicating Full Code/Attempt Resuscitation and Full Treatment, including use of intubation, advanced airway interventions, mechanical ventilation, and transfer to hospital or ICU if indicated. On the night of the incident, a CNA (Staff 5) documented last vital signs for the resident at approximately 10:45 PM, with oxygen saturation of 92% on one liter of oxygen. At 2:00 AM, the resident was observed sleeping, breathing, and with a dry brief. Around 4:00 AM, Staff 5 and another CNA (Staff 8) entered the resident’s room and observed that the resident was not breathing, had yellow skin color, was cool to the touch, and had no palpable pulse. Both CNAs concluded the resident was deceased and went to notify the LPN (Staff 4) instead of initiating CPR or calling a code blue, despite having recent CPR training and later stating that, in retrospect, they would have started CPR and called for a code blue. When Staff 4 (LPN) entered the room, she assessed the resident and found no pulse, blood pressure, or respirations, noted the body was cold, with some mottling on the lower legs, pale/yellowish skin color, and no rigor mortis. Staff 4 did not initiate a code blue or CPR and instead contacted the DNS (Staff 2) and the physician, and then called 911 to obtain the coroner’s phone number. No lifesaving measures were attempted by any staff, despite the resident’s documented full code status and the facility policy requiring CPR in the absence of a valid DNR or signs of irreversible death. The DNS later stated she expected staff to call a code blue immediately, start CPR, call 911, and verify the resident’s code status. Surveyors determined that the facility failed to provide CPR according to the resident’s code status, placing all residents with full code status at risk and constituting substandard quality of care, with the noncompliance cited as Immediate Jeopardy and Past Noncompliance.
Removal Plan
- Administrator, DNS and nursing staff would be re-educated on the code blue process, how to locate a resident's code status in PCC and the POLST on file, and the importance of following individual resident care plans and orders.
- Resident code status would be cross-referenced with the PCC order, POLST scanned in binder, care plan, and resident dashboard.
- DNS or designee would monitor resident code status preferences for new admissions/returning admissions from hospitalizations.
- DNS or designee would audit code status for all new admissions and readmissions from hospitalization or ED visits, and share audit results with the QAPI committee to ensure substantial compliance is maintained.
- DNS or designee would complete a mock code.
- DNS or designee would complete mock codes.
Failure to Initiate CPR for a Full-Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to initiate CPR in accordance with a resident’s documented full code status, physician orders, POLST, and care plan. The resident had multiple diagnoses including hypokalemia, type 2 diabetes mellitus, emphysema, cerebellar stroke syndrome, and congestive heart failure, and was documented as cognitively intact. The physician’s orders and POLST form specified attempt resuscitation/CPR and full treatment, and the care plan stated that CPR would be initiated in the event of cardiac arrest and continued until EMS arrival or a physician order to stop. The resident’s daughter, who was POA, reported that the resident remained alert and oriented until death and had reiterated within the last year that she wished to remain a full code. On the day of the incident, a CNA found the resident unresponsive, without breathing or a pulse, at approximately 8:20 AM and notified the assigned LPN. The CNA reported that the LPN told her the resident was a DNR. The LPN went to the room, verified the resident was not breathing, and did not initiate CPR. Another LPN was called to verify death; as she went to the room, she asked if CPR was needed and believed the first LPN went to check the medical record for code status. The second LPN confirmed there were no heart sounds or respirations and did not initiate CPR. The progress note later documented that the CNA had notified the nurse around 8:20 AM that the resident was no longer breathing or had a pulse, and that another nurse verified there was no pulse/heartbeat and no breathing activity. Subsequently, the second LPN overheard the first LPN on the phone with the physician stating that the resident was a full code. After this, the second LPN reviewed the physician’s orders and confirmed the resident was indeed a full code and reported the issue to the DON. The first LPN told surveyors he did not follow protocol, assumed the resident was a no code based on her appearance, did not review her paperwork to verify code status, and stated he had only received two days of orientation. The DON and Administrator both stated they would have expected nurses to follow facility protocols and administer CPR, and the resident’s physician stated he would have expected the nurse to honor the resident’s wishes and initiate CPR. The facility’s CPR policy required that if an individual is found unresponsive and sudden cardiac arrest is likely, staff should begin CPR and verify code status, initiating basic life support unless a valid DNR order is verified.
Removal Plan
- Re-educate all licensed and direct care staff on CPR requirements, including initiation unless a valid DNR order is present
- In-service all staff on resident code status and where to check code status
- Check off all agency staff on knowledge of CPR and knowledge of code status before working
- Verify all residents' code status to ensure accuracy and accessibility
- Remove any staff involved from resident care pending re-education and competency validation
- Complete hands-on CPR return demonstrations for all staff
- Check emergency equipment (crash cart, oxygen) and confirm it is functional
- Review policy to ensure it clearly requires initiation of CPR unless a valid DNR order is verified
- Add code status verification to shift report and electronic medical record review
- Assign HR responsibility for CPR compliance and education
- Schedule routine mock code drills
- Incorporate CPR requirements into orientation for all new hires
Failure to Provide CPR According to Full Code Status and Physician Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide basic life support, including CPR, in accordance with a resident’s documented full code status and physician orders. The facility’s CPR policy required staff to provide basic life support prior to the arrival of emergency personnel, consistent with the resident’s physician orders and advance directives. The American Heart Association Basic Life Support Algorithm referenced in the report emphasized that high-quality CPR is the most critical part of basic life support and should continue until advanced medical providers arrive or the patient shows signs of life. For this resident, multiple documents, including a Louisiana Physician Orders for Scope of Treatment form, monthly physician orders, hospice certification and plan of care, and the comprehensive care plan, all indicated a full code status, requiring CPR if the resident was unresponsive, pulseless, and not breathing. On the day of the incident, the resident, who had diagnoses including hypertensive heart and chronic kidney disease with heart failure, stage 5 chronic kidney disease, and chronic obstructive pulmonary disease, was found unresponsive and not breathing. Surveillance footage showed that a CNA exited the resident’s room and quickly summoned the CNA supervisor, who then returned to the room and called for additional staff. Two LPNs entered the room shortly thereafter, but video review from the time the incident began until well after showed that no cardiopulmonary emergency equipment, such as a backboard, Ambu bag, or crash cart, was brought into the room. Documentation in a health status note by one of the LPNs stated that she was summoned to the room, found the resident unresponsive and not breathing, and that she attempted CPR but was unsuccessful, with the time of death later documented as pronounced by the hospice nurse. Interviews and video review, however, did not corroborate that CPR was initiated or continued as required. One LPN reported that when she assessed the resident, he had no pulse, was still warm, and showed no signs of prolonged death, but she did not discuss or verify the resident’s code status and assumed the resident was DNR because he was on hospice. She stated she was not aware the resident was full code and had not observed anyone performing CPR. The DON reported that the other LPN had initially believed the resident was DNR and admitted she had not yet implemented CPR; the DON then instructed her to return to the room and start CPR. The hospice nurse stated she was notified that the resident had expired and, upon arrival, found the resident in bed with a sheet over his head and no life-saving measures in progress. She was told that CPR had been started and stopped, but she did not instruct staff to stop CPR and expected it to continue until EMS or a physician directed otherwise. The facility was unable to provide evidence that any licensed nursing staff immediately verified the resident’s code status or ensured continuous CPR from the time the resident was found without a pulse and not breathing until the official time of death, resulting in an Immediate Jeopardy determination.
Removal Plan
- S5LPN was in-serviced on checking Code Status in the Electronic Medication Administration Record (EMAR) and proper procedures for CPR.
- All active residents' EMARs were reviewed to ensure code status was posted.
- All nurses for each shift were in-serviced for checking code status in the EMAR and proper procedures for CPR.
- Implemented a policy to train all nurses on checking code status in the EMAR and proper procedures for CPR prior to working on the floor.
- All new hire nurses will be trained on checking code status and proper procedures for CPR prior to working on the floor.
- Removed the code status binder and red dot stickers; they are no longer in use.
- Required that a resident's code status must be checked in the EMAR.
- The DON will monitor weekly to ensure proper training is provided to all nurses and completed prior to working on the floor.
- The DON will audit training documents prior to scheduling nurses to the floor on a weekly basis and before all new hires.
- The DON will not schedule any nurse who has not completed the required training.
Failure to Initiate Immediate CPR and Provide Adequate BLS and Oxygen Equipment for a Full-Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide proper and effective Basic Life Support (BLS), including immediate CPR, to a resident who was documented as full code. The resident had multiple cardiac-related diagnoses, including diabetes mellitus, congestive heart failure, dementia, atrial fibrillation, and atherosclerotic heart disease, and a POLST indicating that resuscitation/CPR should be attempted with full treatment status. The resident’s care plan identified potential for cardiac distress and directed staff to monitor for symptoms such as dyspnea, shortness of breath, tachycardia, edema, and to promptly contact the physician if symptoms occurred. On the day of the event, the resident had been stable earlier and ate 100% of dinner, but later became weak, had shallow breathing, stopped talking, and became unresponsive. When the change in condition occurred, CNAs observed the resident become unresponsive with eyes rolling back and immediately summoned nursing staff. RN 1 responded and found the resident sitting up at approximately a 70–90 degree angle, unresponsive, with shallow breathing and not verbally responsive, but making noises. RN 1 proceeded to obtain vital signs and reported normal blood pressure, heart rate, respiratory rate, and oxygen saturation initially at 98%, later dropping to 96% and then 89%. Instead of immediately initiating CPR or placing the resident supine on a firm, flat surface with a head-tilt, chin-lift to open the airway, RN 1 left the room to verify code status and retrieve the crash cart. RN 1 stated he did not initiate CPR because the resident made a noise in response to painful stimulation of the ear and he believed this indicated responsiveness. Staff did not initiate chest compressions while the resident remained unresponsive with shallow breathing, and no reassessment of oxygen saturation was documented after oxygen via simple mask was applied. Other licensed staff also failed to initiate BLS measures. LVN 1 reported that when called to the room, the resident was on oxygen via nasal cannula, breathing abnormally with two to three long breaths, and he recognized that 911 needed to be called, but he did not start CPR. LVN 2 stated that the resident was unresponsive and breathing slowly and acknowledged not being aware that ventilation could be provided when a resident is unresponsive and breathing slowly; vital signs she attempted to obtain were not documented. CNA 1 reported that no CPR was initiated by facility staff before EMS arrival. According to the EMS report and the responding Paramedic Captain, paramedics arrived to find the resident supine in bed, unresponsive, pulseless, apneic, and in asystole, with no CPR in progress and no measurable blood pressure, pulse, respirations, or oxygen saturation. The deficiency also included failure to ensure that emergency equipment and oxygen delivery systems were adequate and properly set up for resuscitation. The crash cart contained an oxygen regulator with a maximum output of only 8 L/min, which was insufficient to keep the BVM reservoir bag fully inflated and deliver 100% oxygen as required during resuscitation. The Paramedic Captain reported that the oxygen regulator connected to the resident’s oxygen tank was limited to 8 L/min, and another regulator found in the crash cart was also limited to 8 L/min, necessitating use of EMS’s own regulator to achieve 15 L/min, which delayed delivery of 100% oxygen. The Paramedic Captain also requested a backboard and was informed by RN 1 that the facility did not have one. Additionally, during surveyor observation and interview, RN 1 was unable to determine that the crash cart oxygen tank was empty and could not demonstrate proper connection of the suction tubing to the suction machine, stating he did not know how to determine whether the oxygen tank was empty or how to connect the suction machine. These failures occurred despite facility policies requiring immediate initiation of CPR for unresponsive residents without a DNR and the use of appropriate oxygen administration and emergency procedures. As a result of these findings, surveyors determined that the facility did not initiate immediate CPR for a full-code resident found unresponsive and did not perform continuous, uninterrupted CPR until EMS assumed care. The facility also failed to position the resident flat on a firm surface with airway opened, and failed to ensure availability and proper use of equipment capable of delivering 15 L/min oxygen for BVM use during resuscitation. EMS documentation indicated that no CPR was being performed upon their arrival, and the resident was found in cardiac arrest. The California Department of Public Health determined that the noncompliance constituted Immediate Jeopardy related to failure to ensure CPR was immediately performed on the resident.
Removal Plan
- RN 1 resigned from the facility.
- Staff involved (LVN 1, LVN 2) were removed by the DON from direct patient care until competency was validated.
- Immediate re-education was reinforced by the DON for direct care staff on immediate initiation of CPR, proper positioning on a firm/flat surface, continuous/uninterrupted CPR, crash cart utilization (including oxygen regulators capable of 15 L/min and backboards), and use of oxygen tanks (including how to determine if full or empty).
- Crash cart was checked by the DON and oxygen regulators were replaced to ensure 15 L/min capability; BVM bag and oxygen delivery systems were verified functional; oxygen tanks were ensured full.
- DON and DSD reviewed current certifications of all direct care staff and ensured only staff with validated CPR certification are assigned to residents' care.
- MRD identified residents designated as full code and ensured staff are aware where to find code status in paper medical records and the health record system.
- DON initiated in-service to licensed nurses (RNs/LVNs) and CNAs on the facility CPR emergency procedure policy with emphasis on calling code blue, locating code status, placing resident on firm/flat surface using backboard, head-tilt/chin-lift with oxygen via simple mask, using an oxygen regulator capable of 15 L/min for BVM, and performing continuous/uninterrupted CPR until EMS assumes care.
- Code Blue drills were initiated and will continue for skills check validation via return demonstration of licensed nurses and CNAs.
- A crash cart checklist was developed and implemented; crash cart and oxygen equipment checklist will be checked every shift by the lead licensed staff.
- Room changes will include updating residents' medical records to reflect new room assignment in both the electronic health record and physical medical record.
- A certified CPR instructor provided mandatory re-education and training for all licensed nurses and CNAs with return demonstration conducted.
- DSD/designee will validate that newly hired licensed nurses and CNAs have current valid CPR certification prior to scheduling for direct resident care; no direct care staff will work directly with residents without valid CPR certification.
- DON conducted a 1:1 in-service with LVN 1 and LVN 2 regarding medical emergency response (immediate CPR, proper positioning, continuous/uninterrupted CPR, crash cart utilization including 15 L/min regulators and backboards, and oxygen tank use/verification).
- DSD updated CPR certification status for all current direct care staff and will update monthly; DSD will audit and communicate with staff if CPR certification expires.
- DON/designee will provide a summary of findings for the monthly Quality Assurance Committee (QAC).
Inadequate CPR and Oxygenation for Full-Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate CPR and oxygenation to a resident who was a documented full code. The resident had multiple diagnoses, including hemiplegia and hemiparesis, cerebral infarction, type 2 diabetes, vascular dementia with behaviors, anxiety disorder, dysphagia, and a recent COVID-19 illness. The resident’s POLST and care plan clearly indicated full code status, with instructions that CPR would be initiated if the resident’s heart and respirations stopped. On the night in question, a CNA found the resident unresponsive and not breathing around 4:25 a.m. and notified the LPN, who confirmed the resident’s full code status, called 911, and went to the resident’s room to begin CPR. According to nursing progress notes and staff interviews, the LPN checked for a pulse, found none, and began chest compressions, then the CNA took over compressions while the LPN retrieved the crash cart and called 911. When the LPN returned, she resumed compressions and the CNA began bagging the resident. However, the ambulance run report and paramedic interview documented that upon EMS arrival, one staff member was performing chest compressions and another was attempting ventilation with a BVM that did not have a mask attached and was not connected to oxygen. The paramedic stated that the staff member had only the T-piece in the resident’s mouth and that proper oxygenation with a BVM requires application of the mask. The DON also confirmed that without the mask attached to the bag, adequate ventilation cannot be provided. EMS personnel further observed that staff stopped compressions when EMS entered the room to allow EMS to take over, and that the resident was cold to the touch with rigor mortis noted in the jaw. The LPN later acknowledged that the bed likely was not flattened during CPR and that she found the resident cold with no pulse, stating the resident had not just died minutes before. The facility’s CPR policy required provision of basic life support, including CPR, prior to EMS arrival, and specified the use of a face mask or resuscitator bag to ventilate two breaths after 30 compressions, with each breath delivered over one second to cause chest rise. Despite this policy, the staff’s use of a BVM without a mask and without oxygen, and the failure to ensure proper setup for effective ventilation, resulted in CPR that did not provide adequate oxygenation to the resident.
Failure to Communicate and Update Resident DNR Status Resulting in CPR Contrary to Wishes
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s code status preference was clearly and accurately reflected in the medical record and available to staff, resulting in CPR being initiated contrary to the resident’s documented wishes. The resident was admitted with diagnoses including atrial fibrillation, cardiac disease, stroke, and lung disease, and was initially listed as a full code in the facility’s electronic medical record and on the face sheet. The facility’s practice was to default all new admissions to full code status until staff could confirm the resident’s preferences. The resident had normal cognition on the admission MDS and later completed an Outside Hospital Do-Not-Resuscitate (OHDNR) order, which was signed and dated by both the resident and the physician. The sequence of events leading to the deficiency began when the Admissions Director completed the admission paperwork with the resident, including code status and DNR documentation, and then placed all forms in a folder on their desk before leaving for the weekend. The Admissions Director did not notify nursing staff that the resident’s code status had changed from full code to DNR, did not make copies for the nursing charts, and did not provide the DNR paperwork to the Social Services Director (SSD) or the Director of Nursing (DON). As a result, the SSD created the resident’s electronic profile as a full code and did not receive or review the signed DNR form until after the resident’s death. The DON reported not receiving any DNR paperwork prior to the resident’s cardiopulmonary arrest, and the resident’s orders were not updated in the hard chart, EMR, or on the red/green door sticker system used to indicate code status. When the resident was later found unresponsive, staff followed the information available to them, which indicated the resident was a full code. Staff immediately called the nurse, initiated CPR, and called 911. EMS arrived and continued CPR for over an hour. During this time, the DON was called to the facility and contacted the family while the code was in progress. The resident’s progress notes documented the discovery of the resident unresponsive, the initiation of CPR, EMS involvement, and subsequent notifications to the family and physician. Only after these events did the SSD, while scanning the admission packet into the EMR, discover the signed DNR order that had not been communicated or entered into the resident’s record, confirming that staff had provided CPR despite the resident’s documented DNR preference.
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