Delayed CPR Initiation Due to Nurse's Actions and Lapsed Certification
Penalty
Summary
A deficiency occurred when a nurse failed to immediately initiate cardiopulmonary resuscitation (CPR) for a resident who was a full code and found unresponsive with no pulse. The nurse, whose CPR certification had expired, discovered the resident without signs of breathing or a pulse during a routine check. Instead of starting CPR right away, the nurse left the resident with a CNA, who was not instructed to begin CPR, while he went to call 911, page a code blue, and retrieve the crash cart. This sequence of actions resulted in a delay in the initiation of life-saving measures. Facility policy and American Heart Association guidelines require that CPR be started immediately upon finding an unresponsive individual with no pulse, unless a do-not-resuscitate (DNR) order is in place. The nurse did not follow these protocols, as he prioritized calling for help and gathering equipment over starting chest compressions. The CNA present did not begin CPR and was told to wait for the nurse to return. The Director of Nursing confirmed that the expectation was for the nurse to start CPR while the CNA called for help and retrieved equipment, but this did not occur. The resident involved had significant medical conditions, including chronic kidney disease, hypertension, and type 2 diabetes, and was documented as having severely impaired cognition. The resident was last seen alive a few hours before being found unresponsive. Emergency medical services arrived to find the resident with signs of prolonged downtime and pronounced the resident deceased. The nurse renewed his CPR certification approximately one month after the incident.