Failure to Initiate CPR for Choking Resident with Full Code Status
Penalty
Summary
A deficiency occurred when staff failed to initiate CPR for a resident who was choking, became hypoxic, and unresponsive, despite the resident's documented full code status. The RN supervisor did not assess the resident's airway or respiratory status after the choking incident and only delegated the application of a non-rebreather mask and preparation for transfer, without initiating CPR or further emergency intervention. The resident was admitted with a history of stroke, chronic respiratory failure with hypoxia, and dysphagia, and was cognitively intact at admission. The resident's resuscitation form indicated full code status, requiring CPR in the event of cardiac or respiratory arrest. On the day of the incident, the resident choked while eating, was unable to speak, and exhibited signs of respiratory distress with low oxygen saturation and a high heart rate. Staff did not perform a thorough assessment, such as listening to lung sounds or performing abdominal thrusts, and did not initiate CPR when the resident became unresponsive. Emergency medical personnel arrived to find the resident unresponsive and not receiving CPR, and subsequently initiated resuscitation efforts. The failure to provide basic life support and initiate CPR as required resulted in the resident's death, and an Immediate Jeopardy was declared.