Failure to Provide CPR to Full Code Resident
Penalty
Summary
A deficiency occurred when facility staff failed to provide basic life support, including CPR, to a resident who was found unresponsive and without vital signs. The resident, an elderly male with diagnoses including encephalopathy, heart failure, acute respiratory failure with hypoxia, stage 4 chronic kidney disease, and end-stage renal disease, had a documented Full Code status in his care plan and physician orders. On the evening in question, the resident had returned from a vascular procedure and dialysis, and was last seen alert and without distress. Later, a nurse discovered the resident unresponsive in his wheelchair, with significant blood loss and the dialysis port cap in his hand, indicating the port had been pulled out. Upon finding the resident unresponsive, the nurse checked for vital signs and found none, then called for assistance and 911. Despite being CPR certified and instructed by the 911 dispatcher to begin CPR, the nurse did not initiate any life-saving measures. Other licensed nurses and certified nursing assistants arrived but also did not perform CPR, even after confirming the resident's Full Code status. The crash cart was not brought to the room until after emergency personnel arrived, and no staff attempted to move the resident to a hard surface or begin chest compressions as required by the resident's care plan and facility policy. Interviews with staff confirmed that no CPR or other life-saving interventions were performed prior to the arrival of emergency medical services. The staff involved acknowledged awareness of the resident's Full Code status and their own CPR certification, but did not provide an explanation for their inaction. The facility's management confirmed that the failure to initiate CPR was not in accordance with the resident's advance directives, physician orders, or the facility's procedures for responding to unresponsive residents.