Failure to Initiate CPR for Full Code Resident
Penalty
Summary
The facility failed to initiate life-sustaining measures, specifically CPR, for one resident who was identified as a full code, despite clear documentation and orders indicating that CPR should be performed in the event of cardiac arrest. The resident had a complex medical history, including Amyotrophic Lateral Sclerosis (ALS), and was under hospice care. The resident's care plan and POLST form both indicated that CPR was to be performed if cardiac arrest occurred, and the chart was marked accordingly to reflect this status. On the evening in question, an LPN entered the resident's room to administer medications and found the resident pale, cold to the touch, and not breathing. The nurse checked for a pulse and, finding none, called another nurse to verify the absence of vital signs. Both nurses confirmed the resident had expired, but no attempt was made to initiate CPR. The LPN later stated she assumed the resident was a DNR due to hospice enrollment, despite the documentation indicating otherwise. The incident was later confirmed through interviews and record review, showing that staff did not follow the resident's documented wishes and physician orders regarding resuscitation. Interviews with the resident's power of attorney and physician confirmed that the resident's code status had been changed to full code, with explicit instructions for CPR but no intubation. The physician acknowledged awareness of the full code status and stated that, based on the reported condition of the resident when found, CPR would not have been effective. However, the facility's policy required staff to verify and adhere to each resident's code status, which was not done in this case, resulting in the failure to provide basic life support as ordered.