Failure to Provide CPR According to Resident's Advanced Directive
Penalty
Summary
The facility failed to follow a resident's advanced directives by not providing Cardiopulmonary Resuscitation (CPR) as ordered for a resident with acute and chronic respiratory failure and hypoxia. The resident had a documented advanced directive and physician's order indicating full code status, requiring resuscitation and transfer to an acute hospital in the event of cardiac or respiratory arrest. The care plan included monitoring for respiratory distress and reporting changes to the physician as needed. On the night in question, the resident exhibited signs of respiratory distress, including low blood pressure and decreased oxygen saturation, and received medications accordingly. However, there was no documentation of follow-up on the effectiveness of interventions or notification of the physician regarding the resident's critically low blood pressure. During the overnight shift, the resident was found unresponsive and cold by a CNA, who was unaware of the resident's code status and sought guidance from an LPN. The LPN assessed the resident and determined that CPR was not necessary, stating the resident had clearly passed. No code was called, and CPR was not performed prior to the arrival of emergency medical technicians (EMTs). When EMTs arrived, they found the resident with sheets pulled over her body, no CPR in progress, and staff reported the resident was deceased. The EMTs assessed the resident and pronounced her dead, noting signs of dependent lividity and no trauma. Interviews with staff revealed confusion regarding the process for determining code status and initiating CPR. The CNA reported not knowing the code status and relying on the LPN for direction. The LPN and other staff described facility procedures for code situations, including checking code status and starting CPR until EMS arrives, but these procedures were not followed in this incident. Facility policies required initiation of first aid measures, including CPR, for life-threatening changes in condition, and documentation of all actions taken, which was not evident in the records reviewed.