Failure to Initiate CPR for Full Code Resident
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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Incomplete DNR Forms for Two Residents: Two residents with DNR status had incomplete DNR paperwork. One resident with CKD and severe cognitive impairment had no resident signature on the DNR form, and the physician signed on the wrong line. Another resident with Alzheimer’s disease and severe cognitive impairment had the resident signature on the proxy line, but the physician signature, date, printed name, and license number were missing. The SW and ADM verified the forms were not completed correctly.
Incomplete DNR forms were found for two residents with DNR status. One resident with chronic respiratory failure, heart failure, and type 2 diabetes had a DNR form with the resident’s signature on the wrong line and an undated physician signature, and another resident with renal disease and type 2 diabetes had the resident’s signature on the wrong line with the Person’s Signature line left blank. The DON and SW both verified the missing information and stated the forms were not completed correctly.
Failure to Review Residents’ AD Decisions: The facility did not ensure that 3 residents were informed of and had their AD decisions reviewed. Each resident was able to make needs known and was their own responsible party, but the EHR did not show review of AD decisions on admission or at care conferences. The Social Services Director and Administrator both acknowledged the missing reviews.
A resident with CHF, pulmonary edema, and chronic respiratory failure had care plan and IDT documentation stating an Advance Directive was on file and up to date, but the document could not be found in the record. The ADON stated only a POST form was present, confirmed a POST is not an Advance Directive, and said there was no copy of the resident’s Advance Directive on file.
Failure to Assist Residents With Advance Directive Formulation: Multiple residents had no advance directive in the chart or documented follow-up after social services notes showed they either already had a POA/Living Will or wanted help completing one. Residents with conditions including fx, chronic resp failure, delirium, sepsis, HTN, CKD, AFib, UTI, discitis, and anemia had incomplete documentation, and one care plan had conflicting POA/Living Will information.
Incomplete OOH-DNR Documentation: A resident with severe cognitive impairment, dementia, HTN, CAD, and dysphagia had DNR status documented, but the OOH-DNR form was not fully completed. The form was signed by the qualified relative, yet the attending physician did not sign the required section and the document lacked the physician's dated signature, printed name, and license number; the DON stated the form was still valid based on the witness signature date.
Incomplete DNR Forms for Two Residents
Penalty
Summary
The facility failed to ensure that two residents with documented DNR status had properly completed DNR forms. One resident was a male admitted with chronic kidney disease and acute cystitis with hematuria; his face sheet and physician order summary both reflected DNR status, and his MDS showed severe cognitive impairment with a BIMS score of 6. His DNR form dated 8/06/24 did not contain the resident’s signature, and the physician signed on the line intended for the resident’s signature. The second resident was a female admitted with Alzheimer’s disease and chronic kidney disease; her face sheet and physician order summary also reflected DNR status, and her MDS showed severe cognitive impairment with a BIMS score of 3. Her DNR form dated 09/25/25 had the resident’s signature on the line for a legal guardian, agent, or proxy, but the physician’s signature, date, printed name, and license number were missing. The social worker and administrator both verified the missing information and stated the forms were not valid if not completed correctly.
Incomplete DNR Forms for Two Residents
Penalty
Summary
The facility failed to ensure that two residents with DNR status had completed DNR forms with all required information. Resident #9, a male with chronic respiratory failure, heart failure, and type 2 diabetes, had a DNR order on the physician order summary and a care plan for DNR, but the DNR form showed the resident’s signature on the line for Guardian/Agent/Proxy/Relative Signature, the Person’s Signature line was blank, and the physician’s signature was not dated. Resident #35, a male with renal disease and type 2 diabetes, also had a DNR order and a care plan for DNR, but the DNR form showed the resident’s signature on the line for Guardian/Agent/Proxy/Relative Signature and the Person’s Signature line was blank. During interviews, the DON stated the DNR was not valid if it was not filled out correctly and verified the missing information on the forms for Residents #9 and #35. He stated the SW was responsible for making sure the DNR was completed accurately and that quarterly audits of DNRs were completed for accuracy. The SW also verified the missing information on the DNR forms for both residents and stated she and the resource nurses were responsible for ensuring DNRs were completed correctly. The facility’s Social Services policy stated advance directives would be recognized and respected and that the facility would implement residents’ decisions and directives in compliance with state and federal law and facility policy.
Failure to Review Residents’ Advance Directive Decisions
Penalty
Summary
The facility failed to ensure that residents were informed of their right to establish an advance directive for 3 of 3 sampled residents reviewed for advance directives. Resident 6 was admitted with diagnoses including COPD and diabetes, was able to make needs known, and was their own responsible party, but the electronic health record did not show that the facility reviewed the resident’s advance directive decisions. Resident 11 was admitted with diagnoses including metabolic encephalopathy and diabetes, was able to make needs known, and was their own responsible party, but the record also did not show review of advance directive decisions. Resident 141 was admitted with diagnoses including acute kidney failure and diabetes, was able to make needs known, and was their own responsible party, but the record did not show review of advance directive decisions. During interviews, the Social Services Director stated that residents’ advance directive decisions should be reviewed on admission, at quarterly care conferences, and at the resident’s request. The Social Services Director later stated that Resident 6’s most recent care conference on 02/24/2026 did not include review of the advance directive decision, Resident 11’s initial care conference on 04/07/2026 did not include review, and Resident 141’s most recent care conference on 11/17/2025 did not include review. The Administrator also stated that social services would review advance directive decisions with residents on admission and at quarterly care conferences, and acknowledged that the lack of review for Residents 6, 11, and 141 did not meet expectations.
Advance Directive Not Located in Resident Record
Penalty
Summary
The facility failed to ensure residents exercised their right to formulate an Advance Directive for Resident #33. The State Operations Manual defines an Advance Directive as a written instruction such as a living will or durable power of attorney for health care, and distinguishes a POLST form from an Advance Directive. Resident #33 was readmitted with multiple diagnoses including congestive heart failure, pulmonary edema, and chronic respiratory failure. Resident #33’s care plan, initiated on 5/4/26 and revised on 5/18/26, documented that the resident had an Advance Directive on file and that it was up to date. An IDT Conference Note dated 5/12/26 also documented that the resident’s Advance Directives were reviewed, accurate, and up to date. However, the resident’s Advance Directive could not be located in the record. On 5/28/26, the ADON stated she only saw the resident’s POST form, acknowledged that a POST form is different from an Advance Directive, and stated she did not believe Resident #33 ever gave the facility an Advance Directive; she confirmed there was no copy on file.
Failure to Assist Residents With Advance Directive Formulation
Penalty
Summary
The facility failed to ensure residents and their representatives received assistance to exercise their right to formulate an Advance Directive. Based on policy review, record review, and staff interview, 9 of 12 reviewed residents did not have an advance directive in the medical record or documentation that advance directive information was provided, discussed, or followed up on with the resident or representative. The facility policy stated that on admission the facility would determine whether the patient had executed an advance directive and, if not, determine whether the patient would like to formulate one. Several resident records showed social services notes documenting that the resident either already had a POA/Living Will or wanted assistance obtaining one, but the records did not contain the actual advance directive or documented follow-up. Resident #2, admitted with a nondisplaced left femur fracture and chronic respiratory failure, stated he had a POA/Living Will and that the facility could obtain a copy, but the record did not show an advance directive or follow-up. Resident #37, admitted with a displaced intertrochanteric fracture and delirium, stated she did not have one and wanted assistance making one, yet the record did not document the completed directive at the time of review. Resident #60, with diabetes and anxiety, and Resident #66, with acute embolism/thrombosis and anemia, both stated they had advance directives and would have family provide copies, but no copies or follow-up documentation were present. Additional records also lacked required documentation. Resident #61, with multiple rib fractures and atrial fibrillation, had no advance directive documented and no social services note showing the resident was asked about one or offered assistance. Resident #3, with UTI and discitis, had a social services note indicating she had a POA/Living Will and would let family know, but no advance directive or follow-up was documented. Resident #17, with sepsis and hypertension, had conflicting documentation in social services and care planning records regarding POA/Living Will status, while the baseline care plan did not address advance directive status. Resident #29, with a fractured pubis and chronic kidney disease, and Resident #52, with a fractured hip and hypertension, also lacked advance directive documentation in the medical record.
Incomplete OOH-DNR Documentation
Penalty
Summary
The facility failed to ensure a resident had a properly completed advance directive for Resident #5, whose electronic face sheet listed Advance Directives: DNR. Resident #5 had diagnoses including unspecified dementia with behavioral disturbance, hypertension, atherosclerotic heart disease with angina, and dysphagia. The quarterly MDS reflected a BIMS score of 0, indicating severe cognitive impairment, and the quarterly care plan noted that the resident's family/representative completed documentation for DNR status and that the code status would be reviewed quarterly and as needed. Record review of the resident's OOH-DNR form dated 12/08/22 showed the form was signed by the qualified relative in section C, but the attending physician did not sign section E, and the form did not include the physician's dated signature, printed name, or license number. Section F, which required all persons who signed above to acknowledge the document was properly completed, was also not signed by the physician. During interview, Social Services stated DNR forms must be filled out completely and said forms may not be valid if the physician's dated signature and license number were missing. The DON stated the form was valid and said they went with the date of the witness signature when the physician's signature was not dated.
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