CPR Discontinued Prematurely Without Physician Order
Penalty
Summary
Nursing staff failed to follow established protocols for the initiation and discontinuation of CPR for a resident with diagnoses including orthopedic aftercare and hypertension. The resident had a valid POLST indicating full code status, meaning all resuscitative efforts were to be made in the event of cardiac or respiratory arrest. When the resident was found unresponsive with no signs of life, the licensed nurse verified the absence of an apical pulse and respirations, and, after confirming the full code status, CPR was initiated. However, CPR was discontinued by the nursing staff before the arrival of EMS, and the time of death was declared by a licensed nurse without a physician's order or confirmation of death. Interviews with the involved nurses revealed that CPR was stopped because there were no signs of viability, and the nurse believed the resident had already expired. Both the nurses and the Director of Nursing acknowledged that, according to facility policy, only a physician is authorized to pronounce death, and CPR should have been continued until EMS arrived. The facility's policies also required that CPR/BLS be continued until emergency medical personnel assumed care, which was not followed in this instance.