Failure to Ensure Qualified Staff Provided CPR According to Resident's Plan of Care
Penalty
Summary
The facility failed to ensure that all nursing staff providing care had the necessary skills, knowledge, and certification to perform cardiopulmonary resuscitation (CPR) according to each resident's written plan of care. A resident with multiple complex medical conditions, including chronic respiratory failure, COPD, diabetes, morbid obesity, and congestive heart failure, was admitted as a full code, indicating that all resuscitative measures should be taken in the event of cardiac arrest. However, the resident's care plan did not include a specific plan for code status, and during a cardiac arrest event, not all staff involved were certified in CPR. During the code event, a CNA discovered the resident unresponsive and called for assistance. Several staff members, including LPNs and CNAs, responded and initiated CPR. Interviews revealed that at least one CNA who performed chest compressions was not certified in CPR, and another CNA present was also not certified. The facility's policy required that CPR be performed by staff with appropriate certification, and the expectation was that licensed nurses would provide CPR. Despite this, unqualified staff participated in the resuscitation efforts. The deficiency was further evidenced by the lack of documentation of CPR certification for one CNA in the employee record and the admission by the Nursing Home Administrator that the CNA should not have performed chest compressions. The facility's policy outlined that CPR should be provided to all residents without a DNR order and specified procedures for verifying code status and initiating resuscitation, but these procedures were not fully followed during the incident.