Failure to Administer CPR and Follow Emergency Protocol for Full Code Resident
Penalty
Summary
A deficiency occurred when staff failed to administer cardiopulmonary resuscitation (CPR) to a resident with a documented Full Code status after the resident was found unresponsive and without respirations. The facility's policy and the resident's advance directives required that CPR be initiated in such circumstances unless there were clear signs of irreversible death, which were not documented in this case. The resident was not revived and expired at the facility. The incident involved a resident with multiple medical diagnoses, including arthritis, urinary tract infection, severe malnutrition, congestive heart failure, Alzheimer's disease, COPD, hypotension, and diabetes with chronic kidney disease. The resident was alert and oriented earlier in the shift and had a care plan in place specifying Full Code status, with staff instructed to be aware of and follow the resident's wishes. On the night of the event, a CNA found the resident unresponsive and notified an LPN, who assessed the resident, verified the code status, and initiated CPR. However, the LPN did not call 911 or activate a Code Blue, and stopped CPR after approximately five minutes without further medical direction. Interviews and record reviews revealed that the LPN did not follow facility protocol, which required continuous CPR until EMS arrival and immediate notification of emergency services. The LPN also pronounced the resident's death, which was outside the scope of practice for an LPN, and failed to notify supervisory staff in a timely manner. The facility's policy and staff interviews confirmed that these actions were inconsistent with required procedures for responding to a Full Code resident in cardiac or respiratory arrest.