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:
Advance Directive Not Maintained in Resident Record: A resident with dementia, muscle weakness, and protein-calorie malnutrition had documentation indicating an advance directive was in the chart, but record review did not locate a living will or DPOA for health care. The CNO confirmed the record did not include an advance directive and the facility did not have a living will on file.
Incomplete Advance Directive Documentation: The facility failed to keep complete and accurate advance directive records for two residents. One resident's chart contained a representative-signed acknowledgement that did not specify the type of advance directive, and another resident's record had no signed acknowledgement showing that advance directives were discussed. The SSD stated she was responsible for the documentation and that one form was filled out incorrectly while the other resident's paperwork could not be found.
The facility failed to timely respond to changes in condition for two residents, including one with severe cognitive impairment and another with dementia, CHF, diabetes, and a history of UTIs. Family members and DPOAs reported concerns about confusion, agitation, pain, SOB, and other worsening symptoms, but hospital evaluation was delayed while staff waited for physician input. Both residents were later admitted to the hospital with serious infections and other acute conditions, including sepsis, pneumonia, and respiratory failure.
A facility failed to ensure that active physician orders matched residents’ POLST code status for three residents. One resident with COPD, A-Fib, and anxiety had a POLST indicating DNR but no active code status order; another resident with dementia, hypothyroidism, and HTN had a POLST indicating DNR but a physician order for CPR; and a third resident with COPD, respiratory failure, and diabetes had a POLST indicating DNR but no active code status order. The DON confirmed the records were inconsistent and that physician orders and POLST should match.
A resident with dementia with agitation, stroke, and PE had an advanced directive noted in a care conference review, but the document could not be found in the medical record. Staff later confirmed the resident did not have an advance directive on file.
Failure to offer a resident the opportunity to create an advance directive. Record review showed the resident had no advance directive on file, and the SS Director stated there was no documentation that education was provided or that any attempts were made to obtain one. The resident had HTN, CKD, and mild cognitive impairment.
Advance Directive Not Maintained in Resident Record
Penalty
Summary
The facility failed to ensure that a copy of a resident's advance directive was maintained in the medical record for Resident #32, who was admitted with multiple diagnoses including dementia, muscle weakness, and protein-calorie malnutrition. The resident's care plan, revised 5/12/22, documented that the resident and appointed healthcare representative were to receive education regarding advance directives as needed, and a care conference evaluation dated 6/26/26 documented that the resident had an advance directive in the record. However, on 7/8/26, review of the medical record did not locate a living will or durable power of attorney for health care, and the CNO later confirmed that the record did not include an advance directive and the facility did not have a living will on file.
Incomplete Advance Directive Documentation
Penalty
Summary
The facility failed to ensure documentation regarding advance directives was complete and accurate for 2 of 7 residents reviewed. A policy titled "Advance Directives and Refusal of Treatment" stated that upon admission the Social Services Designee should obtain a copy of any existing Living Will, Health Care Proxy, Durable Power of Attorney for Health Care Decisions, or other recorded declaration and enter a progress note regarding the existence of an advance directive. Resident #7 was admitted with diagnoses including hemiplegia and hemiparesis following a nontraumatic intracerebral hemorrhage affecting the right dominant side. The record contained a "Resident Rights & Advance Directive Acknowledgement" signed by the resident's representative that indicated the resident had an advance directive, but the form did not identify the type of advance directive. Resident #81 was admitted with end stage renal disease, and the medical record contained no signed acknowledgement showing that advance directives were discussed with the resident or representative. The Social Services Director stated she was responsible for advance directive documentation, that the form for Resident #7 was filled out incorrectly and should have been corrected, and that the missing paperwork for Resident #81 meant the facility would not know whether the resident had an advance directive.
Delayed Response to Changes in Condition and Family Requests for Hospital Evaluation
Penalty
Summary
The facility failed to timely provide requested medical evaluation and treatment for two residents with changes in condition. The deficiency was identified during review of Complaint #3035494 and involved delayed responses to worsening symptoms, resulting in delayed medical treatment, worsening of condition, and dissatisfaction with care. For one resident with diagnoses including Alzheimer's disease and other medically complex conditions, the record showed severely impaired cognition and inability to make decisions. A family member reported that the resident had a decline in health about a week before hospitalization, with severe UTI and stool impaction. The hospital record documented that the resident arrived from the nursing home via EMS with confusion and altered mental status that had worsened since several days earlier, and the ED physician suspected sepsis. The resident was febrile, tachycardic, had elevated white blood cell count and creatinine, and was diagnosed with proctitis, cystitis, sepsis, NSTEMI, and acute kidney injury. The urine culture was positive for gram-negative rods/Pseudomonas aeruginosa. For another resident with diagnoses including diabetes mellitus, a history of UTIs, CHF, Alzheimer's disease, and dementia, the progress notes showed family concerns about abnormal behavior, confusion, agitation, shortness of breath, congestion, lethargy, and shallow breathing. The resident's DPOA reported repeatedly expressing concern that something was wrong and requesting hospital evaluation, but the facility did not immediately send the resident out and instead contacted the physician first. The change-in-condition documentation noted altered mental status and respiratory symptoms, and the physician initially recommended a nebulizer treatment before later directing transfer to the ED. The resident was admitted to the hospital with bilateral pneumonia, acute hypoxic respiratory failure, likely demand ischemia, chronic diastolic CHF, fluid overload, severe anemia, and human metapneumovirus infection.
Physician Orders Did Not Match POLST Code Status
Penalty
Summary
The facility failed to ensure that active physician orders reflected residents’ end-of-life wishes as documented on their Pennsylvania POLST forms for three residents. Facility policy stated that residents are presumed to consent to CPR unless there is documentation in the medical record showing a DNR order, and that all DNR orders must be rewritten by the attending physician for each admission or readmission. Review of the clinical records showed that Resident R14 had diagnoses including COPD, A-Fib, and anxiety, and had a POLST indicating DNR, but the current physician orders lacked evidence of code status. Resident R38 had diagnoses including dementia, hypothyroidism, and high blood pressure, and had a POLST indicating DNR; however, a physician order dated in the record indicated CPR, creating inconsistency between the POLST and the physician orders. Resident R50 had diagnoses including COPD, respiratory failure, and diabetes, and had a POLST indicating DNR, but current physician orders also lacked evidence of code status. During interviews, the DON confirmed that Resident R14’s record lacked active physician orders reflecting code status and that Resident R38’s physician orders and POLST were not consistent, and further confirmed that resident physician orders and POLST should match regardless of the POLST.
Advance Directive Not Available in Resident Record
Penalty
Summary
The facility failed to ensure a resident exercised the right to formulate an Advance Directive. Review of the State Operations Manual, record review, and staff interview showed that Resident #5 had an advanced directive documented on a Care Conference Review Comprehensive dated 4/3/26, but the document could not be located in the medical record. Resident #5 was admitted and later readmitted to the facility with diagnoses including dementia with agitation, stroke, and pulmonary embolism. On 6/26/26 at 9:48 AM, a request was made for a copy of Resident #5's advanced directive. Later that day at 11:19 AM, the CEO confirmed that Resident #5 did not have an advanced directive on file. The report states that this deficiency involved 1 of 5 residents whose records were reviewed.
Failure to Offer Advance Directive Opportunity
Penalty
Summary
The facility failed to ensure residents were offered the opportunity to create an advance directive for Resident #13, who was re-admitted with multiple diagnoses including hypertension, chronic kidney disease, and mild cognitive impairment. Record review on 6/24/26 showed that Resident #13 did not have an advance directive on file. On 6/25/26 at 2:43 PM, the Social Service Director stated there was no documentation that education was provided to Resident #13 and no attempts were made to obtain an advance directive.
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