Failure to Honor Advance Directives and Full Code Status During Medical Emergency
Penalty
Summary
The facility failed to honor a resident's Advance Directives and Full Code status when the resident was found unresponsive and without respirations. The resident, who had multiple diagnoses including congestive heart failure, Alzheimer's disease, COPD, and diabetes with chronic kidney disease, was admitted with a documented Full Code status, indicating the desire to be resuscitated in the event of cardiac or respiratory arrest. On the night of the incident, the resident was found unresponsive by a CNA, who notified the assigned LPN. The LPN assessed the resident, verified the Full Code status, and initiated CPR. However, the LPN did not call 911 or activate a Code Blue as required by facility protocol, and stopped CPR after approximately five minutes when it appeared ineffective. The LPN then attempted to contact the provider and notified the resident's family, but did not involve emergency medical services or other nursing staff in a timely manner. Interviews with staff revealed that the LPN was aware of the facility's protocol, which required calling a Code Blue and 911, and continuing CPR until EMS arrived or a physician instructed otherwise. The LPN admitted to not following these steps, stating uncertainty and possible panic as reasons for the omission. The CNA present during the event confirmed that she assisted in moving the resident but was unsure if CPR was performed. The Acting Director of Health Services and other nursing staff were not notified until hours after the incident, and the LPN, who was not authorized to pronounce death, did so without proper authority. The facility's policy and staff interviews confirmed that the correct procedure was not followed, and the resident's Advance Directives were not fully honored. The deficiency was identified as Immediate Jeopardy due to the facility's failure to act in accordance with the resident's Advance Directives and Full Code status, depriving the resident of potentially lifesaving measures. The event was isolated to one resident but demonstrated a breakdown in communication, adherence to protocol, and timely response to a medical emergency. The facility's own policies and staff statements confirmed that the required actions were not taken, resulting in the resident not being revived and expiring in the facility.