Failure to Initiate CPR and Emergency Response for Full Code Resident
Penalty
Summary
Facility staff failed to perform CPR according to standards of practice, did not call a code blue, and did not contact emergency medical services (911) for a resident who was identified as full code on physician orders and in accordance with facility policy. The resident, who had a history of right femur fracture, hypopituitarism, type 2 diabetes, chronic diastolic congestive heart failure, obstructive sleep apnea, and cerebral infarction, was admitted for rehabilitation and was documented as a full code. The resident was found unresponsive, without a pulse, and cool to the touch by a registered nurse, who did not immediately initiate CPR, did not bring the crash cart, and did not use the intercom system to announce a code blue. The nurse was unaware of the resident's code status at the time and sought guidance from a former DON by phone, who instructed her to stop compressions and not to call 911. No assessment for clinical death or rigor mortis was documented. Other staff present during the incident also failed to take appropriate action. An LPN responded to a call for assistance but did not assess the resident, did not call a code blue, did not bring the crash cart, and did not call 911. A CNA entered the room to assist with cleaning the resident but did not initiate emergency procedures or call for help. Staff interviews revealed a lack of knowledge regarding code blue procedures, use of the intercom system, and the process for pronouncing death. The facility did not have a policy regarding nurses determining or pronouncing death, and there was no investigation conducted regarding the resident's death at the time. The facility's policy required immediate action in medical emergencies, including initiation of CPR, announcement of code blue, and calling 911 for residents with full code status. However, these procedures were not followed for the resident in question. The deficiency was identified as Immediate Jeopardy, affecting multiple residents with full code status, due to the failure to provide basic life support and follow established emergency protocols.
Removal Plan
- Administrator/designee will provide training for all staff on Medical Emergency Response and CPR policy. This includes the employee who first witnesses or is first on the site of a medical emergency will initiate immediate action. The training also includes if a resident experiences cardiac arrest or unresponsiveness, the facility staff will provide basic life support including CPR, prior to the arrival of emergency medical services in accordance with the resident's advanced directives. The training will continue until all staff have attended. Agency staff and staff who missed the training will receive training prior to working their next scheduled shift.
- Administrator/designee will provide training for all staff on Resident Rights regarding Treatment and Advance Directives.
- Provide Mock Code evaluation drills in a Mandatory Meeting and continue until all staff have attended a drill. The Mock Code Blue Audit tool will be used during the drill as a guide for staff roles and tasks during a Code Blue. The Administrator/designee will provide the training. The training will continue until all staff have been trained.
- The Maintenance Director will provide training on the use of the intercom system, to announce Code Blue on the overhead page, to all staff, as part of the Mock Code evaluation drills. The training will continue until all staff have been trained.
- The facility developed a process to determine if a resident has executed an advance directive. The Social Service Director reviewed Advance Directive with the residents, and the process is ongoing.
- Upon admission, the Nurse will ensure a resident with an advance directive, will communicate the resident's choice to the Health Care Practitioner and obtain the order, and provide a copy of the Advanced Directive to Social Services/designee, and ongoing.
- The Facility Quality Assurance Committee (Administrator, Regional Director of Operations, Regional Clinical Director and Medical Director) met to review the F678 IJ (Immediate Jeopardy).
- The Facility created a Quality Assurance audit tool to be used by the DON (Director of Nursing)/Designee, for all Licensed Nurses, for Medical Emergency Response. The Audit will be done with every nurse and then twice weekly with random nurses. The results of the Audits will be reviewed with the QA (Quality Assurance) Committee at their monthly meetings.
- The Facility created a QA audit tool to be used by Social Service/designee to assess all new admissions and readmissions for Code Status and or POLST orders, care plan and update the list of resident code status. The audit tool will be done daily, then monthly and then quarterly.