Failure to Document and Record CPR Event for Resident in Cardiac Arrest
Penalty
Summary
The facility failed to provide adequate clinical documentation that continuous Basic Life Support (BLS) and Cardiopulmonary Resuscitation (CPR) were administered to a resident who was found unresponsive and without a pulse. According to the facility's policy, staff are required to initiate CPR following American Heart Association guidelines and document the event in the medical record. However, the facility was unable to produce a code sheet or detailed documentation specifying which staff performed CPR, the steps taken during the event, or the timing of those steps. The resident involved had significant medical conditions, including cerebral infarction, acute respiratory failure, aphasia, dysphasia, epilepsy, diabetes mellitus, and a tracheostomy. The resident was found unresponsive in her room by a respiratory therapist, who noted the absence of a pulse and initiated a code. Progress notes indicated that CPR was started and an AED was applied, with emergency services arriving shortly thereafter. Despite these actions, there was no comprehensive documentation in the medical record detailing the sequence of events, staff roles, or interventions performed during the code. Interviews with staff, including the respiratory therapist, LPNs, and the Director of Nursing, revealed inconsistencies and gaps in the documentation and communication regarding the CPR event. The respiratory therapist acknowledged starting CPR and replacing a dislodged tracheostomy but did not document the tracheostomy incident or report it to other staff or emergency personnel. The Director of Nursing confirmed that documentation of CPR events and reporting of tracheostomy dislodgement are expected but were not found in this case.