Failure to Initiate CPR for Full Code Resident
Penalty
Summary
The facility failed to initiate and provide Basic Life Support (BLS), including Cardiopulmonary Resuscitation (CPR), to a resident who was designated as full code status. According to the facility's policies and the resident's documented preferences, staff were required to perform CPR unless there was a written physician order to the contrary. On the date of the incident, nursing staff found the resident unresponsive, without respirations or a palpable pulse, but did not attempt to perform BLS/CPR as required by both the resident's wishes and physician orders. The resident involved had a medical history that included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD) with acute exacerbation, and pneumonia. The resident was admitted and readmitted to the facility, with documentation confirming full code status and a clear preference for resuscitation efforts in the event of cardiac or respiratory arrest. The medical record, care conference notes, and the Tennessee Physician Orders for Scope of Treatment (POST) form all indicated the resident's desire for full code status, which was discussed and confirmed with both the resident and their representative. On the morning of the incident, the registered nurse assigned to the resident found them unresponsive during routine medication administration. Despite being aware of the resident's full code status, the nurse did not initiate CPR, citing the resident's physical appearance, such as blue fingers and discoloration of the lower extremities, as the reason. Another staff member was told by the nurse that the resident was a Do Not Resuscitate (DNR), which was not accurate. Interviews with other staff and the resident's family confirmed that the expectation was for life-saving measures to be performed in accordance with the resident's wishes. The facility's failure to provide BLS/CPR as required resulted in a citation for substandard quality of care.