Failure to Provide CPR According to Current Standards of Practice
Penalty
Summary
The facility failed to provide cardiopulmonary resuscitation (CPR) according to current standards of practice for one resident who was a full code, as indicated by their POLST form. The resident had multiple diagnoses, including cardiac arrhythmia, congestive heart failure, and was admitted for rehabilitation following a hospital stay for urinary tract infection with sepsis and metabolic encephalopathy. On the day of the incident, the resident was found unresponsive and cold to the touch in the dining room by a CNA, who then brought the resident to the nurse's station. Nursing staff assessed the resident, found no pulse or respirations, and initiated CPR with the assistance of other staff members. Despite having backboards available, staff placed the resident on a soft mattress rather than a firm, flat surface or using a backboard, which is required for effective chest compressions. Staff admitted that in the urgency of the situation, they did not use a backboard or move the resident to the floor. Additionally, staff were not aware of the expectation to periodically check for a femoral or carotid pulse during compressions to verify effective perfusion. The facility's policy and American Red Cross guidelines both require CPR to be performed on a firm, flat surface, and for staff certified in CPR to initiate and maintain resuscitation efforts until emergency responders arrive. Emergency Medical Services arrived and moved the resident to the floor, continued CPR, and used a defibrillator, but the resident was ultimately pronounced deceased. Interviews with staff confirmed that standard procedures for effective CPR, including use of a backboard or firm surface and pulse checks during compressions, were not followed. The Advanced Practice Nurse verified that these steps are expected practice in such situations.