Failure to Initiate CPR for Full Code Resident
Penalty
Summary
A deficiency occurred when facility personnel failed to provide basic life support, including CPR, to a resident who required emergency care prior to the arrival of emergency medical personnel. The resident, an elderly female with severe cognitive impairment, multiple diagnoses including dementia, and a terminal prognosis related to Alzheimer's disease, was admitted as a hospice patient. Her medical records, care plan, and physician orders indicated she was a full code, meaning she should receive resuscitation efforts in the event of cardiac or respiratory arrest. At the time of the incident, the resident's advance directive status was not updated to DNR, as the necessary documentation had not been signed by the responsible party or physician. On the day of the incident, the resident was found unresponsive by family members, who immediately notified the assigned RN. Despite being informed multiple times by family and other staff that the resident was a full code and required CPR, the RN failed to initiate life-saving measures. The RN did not check the resident's code status or follow the physician's orders and facility policy to begin CPR and call 911. Other staff, including a CNA and another RN, became involved after being alerted to the situation. The second RN ultimately initiated CPR, but only after a significant delay and after being verbally notified by the CNA. There was no announcement of a code blue over the PA system, and the initial RN left the room before EMS arrived, failing to communicate with emergency personnel about the resident's condition and care provided. Interviews with staff and review of documentation confirmed that the RN responsible did not follow established protocols for determining code status and initiating emergency response. The failure to provide timely CPR and activate emergency procedures was corroborated by multiple witnesses, including family members, other nursing staff, and hospice personnel. The resident was eventually transported to the hospital by EMS, but later expired. The deficiency was identified as a result of the RN's inaction and lack of adherence to the resident's documented wishes and medical orders.