Failure to Initiate CPR and Contact EMS for Full Code Resident
Penalty
Summary
The facility failed to initiate Cardiopulmonary Resuscitation (CPR) or call 911 for Emergency Medical Services (EMS) for a resident who was found unresponsive, not breathing, and without a pulse, despite having advance directives and a physician order indicating Full Code status. Two LPNs responded to the resident's room after being alerted by a CNA, assessed the resident, and confirmed the absence of vital signs. Neither nurse initiated CPR nor contacted EMS, and instead, they called the time of death without physician direction or the involvement of a qualified health professional. The resident involved had multiple diagnoses, including chronic obstructive pulmonary disease (COPD), dementia, prostate cancer, hypertension, congestive heart failure, and orthostatic hypotension. The resident's care plan and physician orders clearly indicated Full Code status, with interventions specifying to call 911 and initiate CPR in the absence of a pulse. At the time of the incident, a family member was present at the bedside, but there was no documentation or confirmation that the family member or the resident's Power of Attorney (POA) had authorized withholding CPR. Interviews with the resident's daughter and granddaughter confirmed that neither directed staff to withhold life-saving measures. Staff statements revealed that the LPNs did not initiate CPR because they believed the family at bedside refused it, but this was not corroborated by the family members involved. The LPNs also called the time of death, which was outside their scope of practice, and did not seek direction from a physician. The facility's policy required staff to provide basic life support, including CPR, for residents with Full Code status prior to EMS arrival, in accordance with the resident's advanced directives. This failure to follow established protocols and physician orders resulted in the resident passing away without life-saving measures being attempted.