Delayed CPR Initiation for Full Code Resident
Penalty
Summary
The facility failed to timely administer CPR to a resident who was identified as Full Code, resulting in a significant delay of 13 to 20 minutes before lifesaving measures were initiated. The resident, who had a history of hemiparesis and a tracheostomy, was found unresponsive by a CNA, who immediately reported the situation to an LPN. The LPN assessed the resident, noted unresponsiveness and yellowing of the skin, and declared the resident deceased without verifying code status or initiating CPR. The LPN did not call a Code Blue or check the resident's code status at that time. Subsequently, the LPN contacted the DNS for further instructions, and only after being directed to verify code status and start CPR did the LPN begin resuscitation efforts, which occurred 13 to 20 minutes after the initial assessment. During this period, no Code Blue was called, and emergency services were not immediately contacted. Multiple staff interviews confirmed the delay in initiating CPR and the failure to follow established emergency response protocols, including verification of code status and prompt initiation of lifesaving measures for a resident with Full Code status.
Removal Plan
- Re-educating licensed nurses on the process of verifying code status, including POLST or physician orders when residents were observed with no pulse or respirations.
- Reeducated licensed nurses including float and agency nurses on emergency response.
- Medical records conducted audits on all new residents for a signed POLST or physician's order to determine resident's status until substantial compliance was met.
- Audits implemented to ensure proper initiation of emergency CPR services were provided during mock code blue for all shifts with no deficient practice found.