Failure to Provide Timely CPR Due to Code Status Uncertainty and Lack of Staff Training
Summary
A deficiency occurred when facility personnel failed to provide basic life support, including CPR, to a resident who was found unresponsive prior to the arrival of emergency medical personnel. The resident, an elderly female with diagnoses including urinary tract infection, severe obesity, hypertension, and diabetes, was readmitted to the facility and did not have a completed care plan or a clearly documented code status in the electronic health record at the time of the incident. When the resident was found unresponsive and without a pulse, the nurse on duty, LVN A, did not immediately initiate CPR or call for assistance from available staff. Instead, LVN A left the resident to check the code status in the electronic health record and a code status binder, and made multiple phone calls to hospice, the resident's representative, and the facility administrator to determine the resident's code status. This process resulted in a delay of approximately three minutes before CPR was started. Other staff members, including LVN C and LVN D, only began CPR after being informed by LVN A and after searching for the code status themselves. Multiple staff interviews revealed that they had not been trained by the facility on how to respond to an unresponsive resident or on the protocol for initiating CPR and emergency response. Record reviews and staff interviews further indicated that the facility did not have a documented CPR policy, and the existing change in condition policy did not address steps to take when a resident is found unresponsive. The failure to enter the resident's code status at admission, combined with the lack of staff training and clear protocols, contributed to the delay in initiating CPR. This deficiency was identified as Immediate Jeopardy due to the risk of harm from delayed emergency response.
Removal Plan
- Corporate nurse educated the Administrator/Director of Nursing/Assistant Director of Nursing/Social Worker on the expected practice of confirming all new admissions have advance directives elections indicated within the medical record.
- All residents should have a code status election physician's order in place upon admission.
- Any resident who has an advance directive election change should have the election documented and a physician's order should be obtained at the time the election has been voiced. DNR elections will be honored upon the resident/representative having voiced the advanced directive care election and if DNR the OOH-DNR form will be initiated and completed, then uploaded into the electronic health record.
- Licensed Nurses both on-coming, and off-going nurses will review/audit the code status designation for any new admission, re-admission and new order or changes to code status during the 24-hour report. Any identified discrepancies or absence of code status will be reported to the attending MD, DNS and/or ADMIN.
- Should there not be an election of advanced directives or code status, will result in the individual being full code until otherwise directed.
- The Administrator/Director of Nursing/Assistant Director of Nursing/Social Worker will conduct an initial review of the admission/readmission orders to validate that the advanced directive election for code status is in place. This audit will take place during the morning meeting and the RN Supervisor on duty will conduct the audit on the weekends. In the absence of the RN Supervisor on duty, the Director of Nursing or Assistant Director of Nursing will be responsible for conducting the audit to validate code status election orders are in place. Any discrepancies will be immediately clarified with the resident, authorized representative and the appropriate order will be obtained by the attending physician.
- Corporate nurse educated the Administrator/Director of Nursing/Assistant Director of Nursing on response times when performing immediate assessments/interventions for residents with changes in condition.
- Anytime a resident experiences a change in condition and it appears the heart has stopped, pulseless or not breathing, with a Full Code Order or No code status, you must immediately initiate the CPR process, until the code status is validated. The other present licensed nurses in the community must assist with the change in condition by immediately verifying code status, calling 911, notifying MD and RP. As well as assisting with the required paperwork for a hospital transfer.
- The Administrator/Director of Nursing/Assistant Director of Nursing conduct re-education with the identified nurses as well as all other licensed nurses regarding the expected practice of confirming all new admissions, re-admissions have advance directives elections indicated within the medical record.
- All licensed nurses will receive the education regarding the process of reconciling physician orders into the electronic health record accurately and timely to include but not limited to code status upon admission, re-admission and any changes in code status election/advanced directives. No nurse will be allowed to work until the in-service training has been completed.
- DNR elections will be honored upon the resident/representative having voiced the advanced directive care election and if DNR the OOH-DNR form will be initiated and completed with physician's signatures, then uploaded into the electronic health record.
- Nurses are expected to validate the code status election within the electronic health record orders to determine code status ordered, upon identifying that a resident presents with altered signs of life, i.e. absence of detectable vital signs, no s/s of life. Nurse should immediately validate code status order in order to confirm advance directive/code status election prior to initiating CPR. After code status has been swiftly confirmed, the nurse should adhere to the code status election (Full Code = swiftly initiating CPR accordingly or DNR-do not resuscitate the nurse would swift proceed with notifications of no s/s of life to the physician and representative. If full code: The available licensed nurses within the community should assist with the code status response by swiftly verifying the code status order, implementing CPR according to the physician's order, calling 911, and notification to MD and RP, as well as assisting with the required paperwork for a hospital transfer. If you find a resident is found unresponsive, the nurse must yell for help, and then proceed to validate the code status, if the cart with the computer is at the door of the room. In the event the cart is not at the door of the room, the charge nurse must also yell for a team member to bring the computer, the crash cart, and the AED machine.
- Nurses are expected to immediately review the code status orders within the electronic health record in order to identify the resident's code status. This should be immediately with the closest nurse's station computer or closest laptop available. The nurse should respond with urgency, immediately confirming code status and implementing resuscitative measures accordingly.
- Nurses are expected to document findings, interventions/response and notifications within the medical record.
- Nurses are expected to notify the Administrator and/or Director of Nurses for all emergent events, deaths within the facility, significant changes in condition and any concerns regarding CPR emergent response as well as any resident without an identified code status election order.
- The Administrator/Director of Nursing/Assistant Director of Nursing conduct re-education with the identified nurses initially then re-education is provided to all licensed nurses regarding on response times when performing immediate assessments/interventions for residents with changes in condition.
- Director of Nursing/Assistant Director of Nursing conducted an audit to validate all orders have been entered into [facility electronic record system] accurately and timely.
- The Administrator/Director of Nursing/Assistant Director of Nursing out of an abundance of caution, provided re-education to all team members on Abuse /Neglect and Residents Rights.
- Going forward the identified trainings above will also be conducted with new hires accordingly.
- Community will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift.
- Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. These trainings will also be conducted with new hires.
- Director of Nursing/Assistant Director of Nursing conducted 100% re-education was extended to all nurses regarding the expected practice of confirming all new admissions have advance directives elections indicated within the medical record.
- All licensed nurses educated regarding the process of reconciling physician orders into the electronic health record accurately and timely to include but not limited to code status upon admission, re-admission and any changes in code status election/advanced directives.
- Nurses are expected to validate the code status election prior to initiating CPR by reviewing the code status order within the electronic health record. The nurse should immediately alert staff for assistance and all available nursing staff should immediately respond to that location. The nurse will alert staff by utilizing the call light system, phone and /or verbally calling for emergency response assistance to that location.
- Upon identifying the code status election via the physician's order, the nurse should then proceed with initiating CPR. If the person is designated as Full Code as per the code status order. The available nurses within the community should assist with the code status response by swiftly verifying the code status order, implementing CPR according to the physician's order, calling 911, and/or conducting proper notification to MD and RP, as well as assisting with the required paperwork for a hospital transfer.
- Should the resident be designated as DNR-do not resuscitate per physician's order and as per the resident's/representative's wishes, the nurse/nurses would proceed with conducting the proper notifications of no s/s of life to the physician and representative.
- In the event there is no identified code status / advanced directives CPR should be initiated. Resuscitative measures should then only be ceased upon the resident's representative's instruction to stop CPR, confirm the person wished to be DNR and as instructed by physician and/or EMS-medical response team.
- Director of Nurses/Assistant Director of Nurses will conduct training for licensed nurses, aids and medication aids regarding the process for confirming and implementing CPR. Nursing team members will not work until in-service training has been received.
- Mock Code Drills: Director of Nurses/Assistant Director of Nurses will conduct monthly mock code response of both full code and DNR on various shifts.
- Nurses are expected to document findings, interventions/response and notifications within the medical record.
- Licensed Nurses both on-coming, and off-going nurses will review/audit the code status designation for any new admission, re-admission and new order or changes to code status during the 24-hour report. Any identified discrepancies or absence of code status will be reported to the attending MD, DNS and/or ADMIN.
- Should there not be an election of advanced directives or code status, will result in the individual being full code until otherwise directed.
- Nurses are expected to notify the Administrator and/or Director of Nurses for all emergent events, deaths within the facility, significant changes in condition and any concerns regarding CPR emergent response as well as any resident without an identified code status election order.
- All Staff: Any staff member should immediately respond to a code status response with the Crash Cart along with the AED to the bedside of identified resident accordingly.
- The Administrator/Director of Nursing/Assistant Director of Nursing out of an abundance of caution, provided re-education to all team members on Abuse /Neglect and Residents Rights.
- Going forward the identified trainings above will also be conducted with new hires accordingly.
- Community will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift.
- Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. These trainings will also be conducted with new hires.
- Monitoring: The Administrator/Director of Nursing/Assistant Director of Nursing/Social Worker will make weekly random audits validating the electronic health record for accurate code status orders as well as appropriate OOH-DNR form within the medical record. The findings will be reviewed and reported to the QAPI committee, to validate compliance or to identify additional training needs.
- The Director of nurses/Assistant Director of Nurses will conduct weekly skills validations of order entry as well as interview nurses to review the expected practice of validating code status upon admission, validating code status order entry as well as expected process for an emergent response when a significant change in condition (absence of signs of life, no detectable vital signs) has been identified, as well as general interviews with all staff regarding expected response of responding with the crash cart to the designated room accordingly.
- Mock Code Drills: Director of Nurses/Assistant Director of Nurses will conduct monthly mock code response of both full code and DNR on various shifts.
- Director of Nurses/Assistant Director of Nurses will review all admission/re-admission orders daily in the clinical meeting to validate orders are transcribed as per required code status admission orders and will review all orders daily in the clinical meeting to validate compliance of code status election has the appropriate code status election physician's order in place.
- HR/Director of Nurses will conduct CPR certification audit.
- This corrective action plan will remain in place to ensure compliance or to identify any further training needs. Findings of those observations will be reported to the QAPI committee during monthly meeting to establish compliance or identify additional trainings and oversight is required.
- All audits will be placed in a binder and kept for review by HHSC for the revisit to validate to compliance.
- The Administrator/Director of Nursing and Medical Director conducted a Ad Hoc QAPI meeting to review this situation, and the immediate corrective action plan implemented.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to maintain documentation that 14 of 41 licensed nurses had current CPR certification for Healthcare Providers. CPR cards were not available for several RNs and LPNs, and the NHA and DON confirmed the facility did not ensure these nurses maintained current CPR certification in accordance with accepted national standards.
An agency CNA found a full code resident unresponsive, but an agency RN did not check for a pulse or vital signs and did not start CPR before leaving to call EMS and look for help. Staff present were not CPR certified, and EMS arrived to find the resident pulseless and apneic with no CPR started by the facility. The resident later died at the hospital.
Facility staff failed to ensure that an LPN and a CNA maintained current CPR certification while working scheduled shifts. Interviews with the Administrator, DON, and HR Director confirmed that RNs, LPNs, and CNAs were expected to hold active CPR cards, and record review showed the LPN’s CPR had expired before renewal while the CNA could not produce a valid CPR card for the employee file. Staffing schedules showed both employees worked multiple shifts despite the lapse, and the job descriptions for both roles required current CPR certification.
A full-code resident with atrial fibrillation, liver cirrhosis, and osteomyelitis was found unresponsive after a family member alerted staff to breathing trouble. Staff entered the room without emergency equipment, and CPR was not started promptly; records and interviews showed delays in recognizing the emergency, calling Code Blue/911, and bringing in the AED, AMBU bag, and crash cart. The resident later expired, and the death certificate listed myocardial infarction as the cause of death.
LPNs and RNs did not maintain current CPR certification for Healthcare Providers with a required hands-on component. Facility policy required active CPR certification for licensed nurses, but review of certification cards showed that 16 of 33 licensed nurses had only online-only CPR training for non-healthcare providers. The HR Director, NHA, and DON confirmed the deficiency.
A resident with CHF was found unresponsive and CPR was performed even though the chart contained an active DNR order, an MDS indicating DNR, and a POLST choosing DNR and allowing natural death. LN stated she reviewed the physician order at the time and confirmed the resident was DNR, and the DON confirmed the resident's orders and POLST indicated DNR.
Missing Current CPR Certification for Licensed Nurses
Penalty
Summary
The facility failed to maintain documentation that its nursing personnel had current education and certification to provide basic life support, including CPR, prior to the arrival of emergency medical personnel and subject to physician orders and residents’ advance directives. A review of the facility’s CPR policy showed it was intended to ensure timely and appropriate initiation of CPR by licensed nursing staff in accordance with facility policy, resident rights, and federal and state regulations. During the survey, the facility provided a list of 41 currently employed licensed nurses and copies of CPR certification cards for review. CPR certification cards were not available for RN Employees E3, E4, E5, E6, and E7 and LPN Employees E8 through E16, totaling 14 of 41 licensed nurses. In an interview, the Nursing Home Administrator and the DON confirmed that the facility failed to ensure these nursing personnel maintained current CPR certification for Healthcare Providers through a CPR provider whose training included a hands-on session in a physical or virtual instructor-led setting in accordance with accepted national standards.
Failure to Start CPR for Full Code Resident
Penalty
Summary
The facility failed to assess a resident for a pulse or vital signs and failed to immediately start CPR for a resident who was a full code and was found unresponsive. Resident #60 had diagnoses including multiple fractured ribs on the left side, acute respiratory failure with hypoxia and hypercapnia, type 2 diabetes mellitus with diabetic peripheral angiopathy, CHF, PVD, osteoarthritis of the left knee, and atherosclerotic heart disease of the native coronary artery. The resident’s code status was documented as full code, and the care plan stated CPR should be started and EMS called if needed. According to the CCTV timeline and staff statements, an agency CNA found the resident unresponsive during rounds and summoned nursing staff. An agency RN arrived at the room, briefly entered, and then left without taking vital signs, checking for a pulse, or starting CPR. The RN then went to the nurses’ station and made calls while the resident remained without CPR. Other agency CNAs were present, but they were not CPR certified. EMS arrived several minutes later and found the resident unresponsive, pulseless, and apneic, with no evidence that facility staff had started CPR before EMS arrival. The 911 audio, CAD log, EMS report, police report, and witness statements all reflected that the resident was found unresponsive and that the facility did not initiate CPR. The police officer reported staff were standing in the room and did not know what to do, and EMS reported the facility staff did not start CPR and did not know the approximate down time. The hospital record stated the resident had been found unresponsive by nursing facility staff, no CPR had been performed by the facility for over ten minutes, and EMS initiated CPR and ACLS during transport. The resident was later pronounced dead at the hospital.
Failure to Maintain Current CPR Certification for Nursing Staff
Penalty
Summary
The facility failed to ensure that a nurse and a CNA maintained current CPR certification while working in the facility. Surveyor interviews and record review showed that facility leadership and HR stated that RNs, LPNs, and CNAs were required to have active CPR certification, and that CPR was needed because staff would respond during a code until EMS arrived. Despite this, the surveyor was unable to obtain a current CPR certification card for a CNA after multiple requests to the Administrator, Assistant Administrator, and DON, and the HR Director stated that the CNA had not produced a valid CPR certification for the employee file. Record review also showed that an LPN had worked multiple night shifts while her CPR certification had expired. The LPN confirmed receiving an HR email about the expiration and stated she renewed her CPR certification on the day of the interview. The expired CPR certificate showed the prior certification had lapsed before the renewal date. The HR Director stated she had sent an email about the upcoming expiration but did not follow up after returning from medical leave. Daily staffing schedules showed that the LPN and CNA worked multiple shifts during the review period despite not having active CPR certification. The facility’s job descriptions for both LPNs and CNAs stated that current CPR certification was required. The facility census report showed 149 residents in the facility at the time of the survey.
Delayed CPR Initiation for Full-Code Resident
Penalty
Summary
The facility failed to initiate CPR in a timely manner for a resident who was full code and found unresponsive. The resident had diagnoses including atrial fibrillation, liver cirrhosis, and osteomyelitis of the right ankle and foot, and the MDS documented moderately impaired cognition. The medical orders, MOLST, and care plan all documented full code/CPR status. Surveillance video showed that after a family member alerted staff that the resident was unresponsive, RN #11 and PCT #5 entered the room without emergency equipment. RN #12, the Assistant DON, later entered the room without equipment, and no medical equipment was observed being brought to the room for several minutes. The video also showed multiple staff entering and exiting the room over time, with the AED, AMBU bag, cardiac board, and crash cart not brought in until much later. The Code Blue/CPR worksheet documented CPR as initiated at 7:01 PM, while other records and staff statements reflected delays and inconsistent times for when the resident was found, when CPR began, and when EMS was called. Staff interviews described that the resident was breathing slowly at first, then became unresponsive, with inability to obtain a pulse or blood pressure. PCTs stated they notified RN #11 after the family member reported trouble breathing, and one PCT stated RN #12 said the resident had already passed away before CPR began. RN #14 stated they responded to an overhead Code Blue and saw RN #12 performing CPR, while the DON later stated the facility’s investigation found CPR was not initiated until RN #13 entered the room. The resident expired at 7:22 PM, and the death certificate listed myocardial infarction as the cause of death.
LPNs and RNs Lacked Acceptable CPR Certification
Penalty
Summary
Facility nursing personnel did not maintain current CPR certification for Healthcare Providers through a CPR provider whose training included a hands-on session either in a physical or virtual instructor-led setting in accordance with accepted national standards for 16 of 33 licensed nurses. The affected staff included LPNs E1 through E12 and RNs E13 through E16. The facility policy titled Cardiopulmonary Resuscitation CPR stated that licensed nurses, respiratory therapists, and van drivers must hold active CPR certification for healthcare providers, and that online-only courses were not acceptable. Review of the CPR certification cards for the 16 licensed nurses showed that their certification was from an online-only CPR class for non-healthcare providers and did not include a hands-on session. During an interview, the Human Resources Director confirmed that these employees did not have the appropriate CPR certification for licensed nurses. The Nursing Home Administrator and the DON also confirmed that the facility failed to ensure that facility nursing personnel maintained current CPR certification for Healthcare Providers through a CPR provider whose training included a hands-on session either in a physical or virtual instructor-led setting.
CPR Performed Despite Active DNR Order
Penalty
Summary
The facility failed to confirm the code status of Resident 96 during an emergency when LN 3 performed CPR after the resident was found unresponsive. Resident 96 had been readmitted with a diagnosis of congestive heart failure, and the record showed an active physician order for DNR, along with an MDS assessment and POLST indicating DNR and allowing natural death to occur. During interview, LN 3 stated CPR was performed after Resident 96 was found unresponsive and that she reviewed the physician order at that time and confirmed the resident's code status was DNR. The MDS Coordinator confirmed the POLST and MDS assessment indicated DNR, and the DON confirmed the OSR showed an active DNR order and stated the physician's order and POLST were expected to be carried out correctly; otherwise, the resident's wishes were not honored.
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