Failure to Immediately Initiate CPR for Unresponsive Resident
Penalty
Summary
Facility staff failed to immediately initiate cardiopulmonary resuscitation (CPR) in accordance with American Heart Association (AHA) guidelines for a resident who was found unresponsive in the patio. The resident had a valid Physician Orders for Life-Sustaining Treatment (POLST) indicating a desire for full resuscitation and no advance directive limiting care. Upon discovery, the resident was unresponsive, with no vital signs appreciated, and was seated in a wheelchair. Instead of starting CPR at the location where the resident was found, staff moved the resident from the patio to his room before initiating CPR. Multiple staff members, including a Registered Nurse Supervisor (RNS), were involved in transferring the resident back to bed, which required six to seven people. Interviews with staff and another resident confirmed that CPR was not started on the patio, despite the resident being unresponsive and pulseless. The facility's policy and AHA guidelines both require immediate initiation of CPR when a person is found unresponsive and not breathing normally, but this was not followed in this instance. The delay in starting CPR was further corroborated by interviews with staff, a resident witness, and the facility's medical doctor, who all stated that CPR should have been started immediately at the site where the resident was found. The medical doctor also confirmed that the patio floor was an appropriate surface for CPR. Paramedics arrived after the resident had been moved to his room and found the resident pulseless and unresponsive, with CPR in progress. The resident was pronounced dead by paramedics after resuscitation efforts were unsuccessful.