Failure to Provide Timely CPR and Notify Physician of Change in Condition
Penalty
Summary
A deficiency occurred when facility staff failed to provide timely Cardiopulmonary Resuscitation (CPR) to a resident who was found pulseless and not breathing, despite the resident having a documented full code status and no valid Do Not Resuscitate (DNR) order in the medical record. The LPN on duty observed a significant drop in the resident's oxygen saturation to 84% with supplemental oxygen but did not notify the medical provider or document any interventions regarding this change in condition. Later, when the resident was found unresponsive, there was confusion among staff regarding the resident's code status due to conflicting documentation between the hospital transfer form and the facility's records. Multiple staff members, including LPNs and CNAs, reviewed the resident's electronic health record and paper chart, confirming the absence of a DNR form and the presence of a full code order. Despite this, the LPN delayed initiating CPR, instead contacting facility administration, hospice, and the medical team, which resulted in a delay of approximately 45-60 minutes before chest compressions and ventilation were started. During this period, staff were uncertain about the appropriate course of action, and some began preparing for postmortem care before CPR was initiated. The resident had a complex medical history, including metabolic encephalopathy, multiple sclerosis, sepsis, dysphagia, acute respiratory failure with hypoxia, diabetes, pneumonia, acute kidney failure, myocardial infarct, and hypertension. The resident was cognitively intact and had previously expressed a desire to remain full code, as documented in care planning and social service notes. The failure to promptly notify the physician of the change in condition and to honor the resident's advance directive for full code status resulted in the resident's wishes for resuscitation not being honored.
Removal Plan
- An audit of each resident's code status was completed.
- The licensed nurse was suspended, pending the facility's investigation.
- A Quality Improvement Performance Committee (QAPI) was conducted to review recommendations from the root cause analysis.
- A performance improvement plan was developed and initiated based on root cause analysis as determined by the QAPI committee.
- Code blue drills were completed for all staff with results reported to the QAPI committee.
- The regional director of social services provided education to licensed nurses and the interdisciplinary team on advanced directives including identification of a valid DNR and who can initiate a DNR, with a posttest upon completion.
- Licensed nurses and CNAs received education on the CPR policy and procedure including responding to a code blue and the roles/responsibilities during a code.
- Staff received education related to the abuse, neglect, exploitation, and misappropriation policy.
- Licensed nurses received education on the identification of a change in condition including competency.
- Newly hired licensed nurses will receive education to include the CPR policy/procedure, advanced directives policy/procedure, identification of change in condition with competency, abuse/neglect/exploitation/misappropriation, and participation in code blue drills.
- Ongoing training is being conducted for the identification of change in condition with competency.