Failure to Initiate CPR for Full Code Resident
Penalty
Summary
Staff failed to provide cardiopulmonary resuscitation (CPR) to a resident who had a documented full code status and had expressed a desire for resuscitative measures. The resident was found unresponsive, pulseless, and cyanotic by a certified nurse aide (CNA), who immediately called for a nurse. The CNA and another CNA checked for a pulse and found none, but neither was aware of the resident's code status at the time. The nurse on duty arrived several minutes later, assessed the resident, and determined that the time to start CPR had expired, despite knowing the resident was a full code. No resuscitative efforts were initiated by any staff present. The resident's medical record indicated multiple serious health conditions, including pleural effusions, pneumothorax, hypoxemia, heart failure, and atrial flutter. The resident required continuous oxygen and had moderate cognitive impairment, needing assistance with most activities of daily living. The care plan and physician orders clearly documented the resident's full code status and the expectation that CPR would be initiated if the resident's heart or breathing ceased. Staff present at the time of the incident, including two licensed nurses and two CNAs, all held current Basic Life Support (BLS) certification and had participated in recent CPR drills. Despite the facility's policy requiring CPR to be initiated for any unresponsive individual without a do-not-resuscitate (DNR) order or clear signs of irreversible death, staff did not begin resuscitative measures. The nurse in charge made the decision not to start CPR, believing it would not be beneficial due to the resident's condition and the time elapsed. This failure to initiate CPR for a resident with full code status constituted a deficiency and placed all residents with similar code status at risk.