Failure to Initiate CPR for Full Code Resident
Penalty
Summary
A deficiency occurred when facility staff failed to honor a resident's advance directive for resuscitation. The resident, who had chronic respiratory failure, a tracheostomy, and was designated as Full Code, was found unresponsive by staff. Despite clear physician orders and care plan documentation indicating the resident's wish for full resuscitative measures, the nurses present did not initiate a Code Blue or begin CPR as required by facility policy and the resident's advance directive. The two LPNs involved assessed the resident and determined the individual was deceased without verifying the presence of the required code bracelet on both arms, as per facility protocol. One LPN only checked one arm for the bracelet and, not seeing it, did not proceed with resuscitation. Both LPNs left the room and notified the RN Supervisor that the resident had expired, but did not call a Code Blue or attempt CPR. The RN Supervisor, upon being notified, prioritized another Code Blue on a different unit, assuming the unresponsive resident had a DNR order due to the lack of an emergent call and absence of a Code Blue being called. It was only after the RN Supervisor returned to the unit and confirmed the resident's Full Code status that a Code Blue was called and CPR was initiated, but this was significantly delayed. The resident was subsequently transported to the emergency department, where resuscitation efforts continued unsuccessfully and the resident was pronounced deceased. Interviews with staff revealed lapses in judgment and failure to follow established protocols for responding to unresponsive residents with Full Code status.
Removal Plan
- Licensed Practical Nurse #1 and Licensed Practical Nurse #2 were suspended immediately following the incident.
- Facility policies for Basic Life Support and Cardiopulmonary Resuscitation, Code Blue, Cardiopulmonary Resuscitation Certification, Advance Directives and Determination of Death were all reviewed and completed.
- Re-education and staff knowledge competencies of licensed nursing staff and certified nurse aides for Basic Life Support and Cardiopulmonary Resuscitation, and Code Blue Procedure, were initiated.
- The facility would add and conduct cardiopulmonary resuscitation and basic life support training to a semi-annual schedule with competencies.
- The facility would add and conduct semi-annual cardiopulmonary resuscitation drills across all shifts.
- All residents' Advance Directives were audited and completed.
- All residents' Full Code (heart symbol) bracelets were audited and completed.
- All licensed staffs' cardiopulmonary resuscitation certifications were audited and completed.
- All staff present on the unit at the time of the incident were interviewed.
- Resident #1's medical record and staff statements were reviewed and completed.
- A Root Cause Analysis of the incident and Quality Assurance and Performance Improvement meeting was initiated and completed.
- Resident deaths in the last six (6) months were reviewed.
- A Quality Assurance and Performance Improvement for Basic Life Support and Cardiopulmonary Resuscitation was initiated.
- Licensed Practical Nurse #1 was terminated from employment and reported to the New York State Office of Professions Licensing Board.
- Licensed Practical Nurse #2 was terminated from employment and reported to the New York State Office of Professions Licensing Board.
- There would be unannounced, random staff knowledge competencies for Code Blue and Cardiopulmonary Resuscitation and the results would be reported to the Quality Assurance and Performance Improvement Committee. The Quality Assurance and Performance Improvement Committee would determine the need for ongoing monitoring. The responsible party would be the Director of Nursing/Assistant Director of Nursing.
- Mock Code and Cardiopulmonary Resuscitation Drills and post-review would be done across all shifts. The performance reviews/results would be presented to the Quality Assurance and Performance Improvement Committee. The Quality Assurance and Performance Improvement Committee would determine the need for ongoing reporting. The responsible party would be the Director of Nursing/Director of Education.
- The audits on Full Code (cardiopulmonary resuscitation) identifier bracelets would be done and results would be reported to the Quality Assurance and Performance Improvement Committee. The Quality Assurance and Performance Improvement Committee would then determine the need for ongoing reporting. The responsible party would be the Director of Nursing/Assistant Director of Nursing.
- An audit tool was developed to track every admission and re-admission's Advanced Directives. The responsible party would be the Director of Nursing/Assistant Director of Nursing.
- A comprehensive education syllabus was in development for presentation at orientation and annually on the following topics: Advance Directives, Code Blue, Cardiopulmonary Resuscitation, and Nurse Scope of Duties. The responsible party would be the Director of Nursing/Assistant Director of Nursing.
- All licensed nursing staff were educated on Acute Changes in Condition: Basic Life Support and Cardiopulmonary Resuscitation, and Code Blue Procedure.