Failure to Initiate CPR for Full Code Resident
Penalty
Summary
Facility staff failed to perform Cardio-Pulmonary Resuscitation (CPR) on a resident who was found unresponsive, despite the resident having a physician order and a signed POLST form indicating full code status and a desire for life-sustaining treatment. The resident was admitted with diagnoses including a left femur fracture, malnutrition, and dysphagia, and was documented as cognitively intact. When the resident was discovered unresponsive, staff did not check the POLST form or initiate CPR, even though the facility's policy required immediate basic life support for residents with full code status unless there were clear signs of irreversible death. Multiple staff members, including LPNs and a nurse manager, were involved in the response. The first nurse to assess the resident did not find a pulse or signs of breathing and assumed the resident was on hospice, failing to verify the code status. The assigned nurse, who was on break at the time, also did not check the POLST form or initiate CPR upon returning to the room. Instead, staff contacted the nurse manager and were instructed to call the family, 911, and the coroner, but there was a significant delay before emergency services were contacted. No staff member performed CPR prior to the arrival of EMS. EMS arrived to find the resident warm to the touch, without rigor mortis or dependent lividity, and initiated CPR upon arrival. Documentation and interviews confirmed that no facility staff had performed CPR, and the resident's code status was only clarified when EMS inquired. The facility's failure to ensure staff were trained to respond appropriately to a resident requiring CPR, to locate and reference POLST/advance directives, and to accurately assess for signs of irreversible death led to the deficiency.