Failure to Initiate CPR for Full Code Resident Due to Delayed Access to Advance Directives
Penalty
Summary
A deficiency occurred when staff failed to provide basic life support (BLS), including cardiopulmonary resuscitation (CPR), to a resident who was found unresponsive on the toilet, despite the resident's advance directive indicating full code status. Certified Nursing Assistants (CNAs) discovered the resident in distress and alerted an LPN, who assessed the resident and found no pulse. Instead of initiating immediate CPR, the LPN sought guidance from another LPN on a different floor, who then contacted the Unit Manager at home for advice on locating the resident's advance directives. During this time, the LPN was unable to quickly access the resident's code status due to difficulties finding the medical chart and lack of immediate computer access. The delay in action resulted in no CPR being performed while staff attempted to confirm the resident's code status. EMS was contacted and arrived to find the resident deceased, with rigor mortis and other signs of irreversible death present. EMS staff indicated it was too late for resuscitation efforts. The resident was left slumped over on the toilet until EMS arrived, and staff did not attempt to move the resident or initiate life-saving measures as required by the facility's policy and the resident's documented wishes. The resident involved had a history of cognitive, social, and emotional deficits following cerebrovascular disease, mild vascular dementia, chronic obstructive pulmonary disease, atrial fibrillation, congestive heart failure, polyosteoarthritis, and a previous myocardial infarction. The resident's physician orders and care plan clearly indicated a full code status, meaning all life-saving measures were to be used in a medical emergency. Despite this, the staff's failure to promptly initiate CPR and their inability to access the resident's advance directives in a timely manner directly contributed to the deficiency.
Removal Plan
- The Director of Nursing (DON) provided education on Advance Directives, location of advanced directives, change of condition, and immediate response of CPR to all staff.
- Training was verified by review of sign in sheets.
- The DON and Administrator interviewed and/or collected statements from all staff working at the time of the incident involving Resident #61.
- A whole house audit of all residents was completed by the Regional Director of Clinical Services (RDCS) verifying code status, care plans and signed Do Not Resuscitate (DNR) forms.
- The Human Resource Director reviewed all nursing staff files to verify cardiopulmonary resuscitation (CPR) certifications were valid.
- The RDCS verified all laptops on the units were accounted for and available for nursing access.
- The DON audited crash carts to ensure all equipment was in place.
- An ADHOC Quality Assurance and Performance Improvement (QAPI) meeting was completed to discuss Advance Directives for all residents and develop education pertaining to Advance Directives, location of advanced directives, change in condition, and immediate response of CPR.
- A second ADHOC QAPI meeting was held to discuss code status levels, staff response expectations, and implementation/adjustment of the corrective action plan.
- Staff received education on advanced directives, location of the advanced directives, immediate response of CPR and change in condition by the RDCS and DON, with completion verified via sign-in sheets and random staff interviews.
- The facility implemented a plan for the DON/Designee to conduct Code Blue drills and location of advance directives on alternating shifts.
- The facility implemented a plan for the Administrator/Designee to audit all deaths to ensure resident's advanced directives were honored per preference.
- The facility implemented a plan for the DON/Designee to conduct audits to ensure that residents' change in conditions were addressed.
- The facility implemented a plan for the DON/Designee to conduct audits to ensure each unit had a laptop for nursing access.