Failure to Initiate CPR and Timely EMS Response for Full Code Resident
Penalty
Summary
Facility staff failed to protect a resident's right to be free from neglect by not initiating Cardiopulmonary Resuscitation (CPR) or calling Emergency Medical Services (EMS) in a timely manner during a medical emergency. The resident, who had a history of left femur fracture, malnutrition, and dysphagia, was found unresponsive, pulseless, and not breathing. Despite the resident's documented wishes and physician orders for full code status and CPR, staff did not check the resident's POLST form or initiate CPR as required by facility policy. Multiple staff members, including two LPNs, assessed the unresponsive resident but did not begin CPR or immediately contact EMS. One LPN incorrectly assumed the resident was on hospice and did not verify code status, while another admitted to being in shock and did not use a stethoscope to confirm the absence of vital signs. Both staff members acknowledged they should have checked the POLST form and initiated CPR but failed to do so. The delay in action resulted in a 45-minute gap before EMS was called and CPR was started by EMS personnel upon arrival. Interviews with facility leadership and staff confirmed that the expectation was to check the POLST form and initiate CPR immediately for residents with full code status. Documentation and staff statements revealed that no facility staff performed CPR prior to EMS arrival, and the resident was still warm to the touch without signs of irreversible death when EMS began resuscitation efforts. The failure to follow established protocols and physician orders led to unmet care needs and was identified as neglect.