Failure to Timely Initiate CPR for Full Code Resident
Penalty
Summary
A deficiency occurred when facility staff failed to initiate cardiopulmonary resuscitation (CPR) immediately for a resident with a full code status who was found unresponsive and without vital signs. The resident had a physician's order indicating full code status and had been admitted with diagnoses including bladder cancer, stage 3 kidney disease, and absence of a kidney. On the day of the incident, the resident was last observed sitting up in bed and later was found by a family member to be unresponsive, not breathing, and with open mouth and eyes. The family member alerted staff, who responded to the room. Upon entering the room, staff, including CNAs and LPNs, checked for vital signs and found none. Instead of immediately initiating CPR, staff moved the resident onto the bed, cleaned the resident, and put on a gown and brief. Multiple staff members, including nurses and CNAs, were present, but CPR was not started right away. There was confusion among staff regarding the resident's code status and who was responsible for initiating CPR. Some staff waited for direction from a supervisor, and others were occupied with checking for code status in binders or the electronic health record. According to interviews, there was a delay of several minutes before CPR was initiated, and 911 was called only after this delay. Staff interviews revealed inconsistent understanding of the process for identifying code status and when to begin CPR. Some staff believed only nurses should initiate CPR, while others were unsure of their roles during a code. The delay in starting CPR was attributed to waiting for confirmation of code status and for instructions from supervisory staff. The resident ultimately did not receive timely CPR as required by facility policy and physician orders, and was later pronounced deceased by emergency medical services.