Failure to Continue CPR Until EMS Arrival for Full Code Resident
Penalty
Summary
The facility failed to ensure that Cardio-Pulmonary Resuscitation (CPR) was initiated and continued for a resident with a Full Code status who was found unresponsive and without vital signs. The resident had a documented Physician Orders for Scope of Treatment (POST) form indicating the desire to receive CPR in the event of cardiac or respiratory arrest. Despite this, staff members started CPR but discontinued it prior to the arrival of emergency medical services (EMS). On the night of the incident, an LPN and a nurse aide discovered the resident unresponsive during a routine check. They reportedly performed three to four rounds of CPR but stopped several minutes before EMS arrived. The nurse aide left the room to answer another resident's call light, and the LPN did not continue resuscitation efforts. The crash cart was obtained, and 911 was called, but CPR was not maintained until EMS took over, as required by the facility's policy and the resident's code status. The facility's investigation confirmed that the staff did not follow the established CPR policy, which mandates that CPR be provided and continued until EMS arrives unless there are obvious signs of irreversible death. Written statements from staff and interviews corroborated that CPR was stopped prematurely, and the responsible staff members were subject to disciplinary action. The deficiency resulted in the death of the resident and had the potential to affect all residents with a Full Code status.