Failure to Initiate CPR and Activate EMS for Full Code Resident
Penalty
Summary
The facility failed to ensure that Basic Life Support (BLS), including Cardio-Pulmonary Resuscitation (CPR), was initiated immediately for a resident who was found unresponsive, not breathing, and without a pulse, despite the resident having a current physician order and POLST form indicating Full Code status. The facility's policy required staff to activate Emergency Medical Services (EMS) and begin CPR without delay unless a Do Not Resuscitate order was in place or there were obvious signs of irreversible death. However, when the resident was discovered in this condition, the first licensed staff member on the scene did not initiate CPR or call EMS, instead leaving the resident to notify the Director of Nursing (DON). The staff member who found the resident admitted to panicking and failing to assess for signs of irreversible death or to start CPR as required. Two certified nursing assistants were also present in the room but did not initiate CPR. Review of staff credentials revealed that the registered nurse on the scene had a current CPR certification, but both certified nursing assistants had expired CPR cards at the time of the incident. The facility did not have a process in place to ensure that staff CPR certifications were current and reviewed before expiration. As a result of these actions and inactions, CPR was not performed, and EMS was not called for the resident, who was subsequently pronounced deceased by a physician assistant. The deficiency was identified as placing additional residents with Full Code status at serious risk, as the facility had 48 other residents with current physician orders to receive CPR according to policy.