Failure to Provide Immediate and Continuous CPR to Full Code Resident
Penalty
Summary
A deficiency occurred when staff failed to immediately initiate and continuously perform cardiopulmonary resuscitation (CPR) on a resident who was identified as Full Code status and was found unresponsive without vital signs. Upon discovery, staff delayed the start of CPR while attempting to confirm the resident's code status, and once CPR was initiated, it was not maintained until emergency medical services (EMS) arrived. Instead, the registered nurse in charge stopped CPR after only one cycle, despite the resident's Full Code status and the absence of a physician's order to discontinue resuscitative efforts. The resident involved had a history of chronic obstructive pulmonary disease, atrial fibrillation, bipolar disorder, and acute respiratory failure, and was noted to have intact cognition and independent ambulation prior to the incident. On the day of the event, the resident was found unresponsive, cyanotic, and pulseless by staff. Multiple staff interviews and statements revealed confusion and lack of coordination regarding the resident's code status, delays in retrieving and using the crash cart, and the absence of essential equipment such as a backboard, oxygen, and a face mask for the Ambu bag. Staff resorted to improvising with a paper towel for rescue breaths due to missing equipment. EMS arrived to find that CPR had been stopped for approximately five minutes prior to their arrival, and immediately resumed life-saving measures. Staff interviews consistently indicated that the registered nurse in charge directed staff to stop CPR, asserting authority to call the code, despite objections from other staff members who recognized that CPR should have continued until EMS arrival. The failure to provide immediate and continuous CPR as required by the resident's Full Code status and facility policy resulted in serious life-threatening harm and/or death.