Failure to Initiate Timely CPR and Emergency Response for Full Code Resident
Penalty
Summary
The facility failed to ensure that nursing staff were knowledgeable and able to correctly state and follow the facility's policy regarding the initiation of Cardiopulmonary Resuscitation (CPR) and Basic Life Support (BLS). Four out of six nursing staff interviewed were unable to accurately describe the policy, and there was inconsistency among staff regarding who should initiate CPR and how to activate emergency response systems. Some staff were unsure about the use of the paging system and the process for verifying code status, leading to delays in emergency response. A resident with multiple medical conditions, including diabetes, hypertension, and heart disease, was found unresponsive, not breathing, and pulseless in her bed. Despite having a Physician Orders for Life-Sustaining Treatment (POLST) indicating a full code status and a desire for resuscitation, nursing staff delayed the initiation of CPR while attempting to verify the resident's code status. Documentation and interviews revealed that staff did not immediately begin CPR, and there was confusion about who should call 911 and how to summon additional help. The facility's policy required immediate initiation of CPR by certified staff and activation of emergency response, but these steps were not promptly followed. Additionally, the facility did not have an Automated External Defibrillator (AED) available for use during the resuscitation attempt, despite policy and best practice expectations. Only some of the licensed nurses were currently certified in CPR/BLS at the time of the incident. These failures reduced the likelihood of successful resuscitation for the resident and potentially for other residents identified as full code.