Failure to Timely Initiate CPR and Honor Full Code Status
Penalty
Summary
A facility failed to implement timely Cardiopulmonary Resuscitation (CPR) and did not honor a resident's full code status, resulting in a deficiency. The resident, who had a documented full code order and had expressed a desire to be resuscitated, experienced a significant drop in oxygen saturation, which was not reported to a medical provider nor were interventions documented. Later, when the resident was found pulseless and not breathing, staff delayed initiating CPR due to confusion over the resident's code status, despite the absence of a Do Not Resuscitate (DNR) form and the presence of a full code order in the electronic health record. The delay was exacerbated by staff reviewing conflicting documentation and seeking guidance from supervisors and hospice rather than immediately starting resuscitation efforts. One LPN was confused by a hospital transfer form indicating DNR status, but the facility's records and care plan clearly indicated full code. During this period, staff did not promptly call a code or begin chest compressions, and instead contacted administration, hospice, and the medical team, resulting in a delay of approximately 45-60 minutes before CPR was initiated. The resident's medical history included multiple serious conditions such as 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 actively participated in care planning, consistently expressing a wish to remain full code. The failure to promptly initiate CPR and honor the resident's wishes led to the resident's death and was determined to be an Immediate Jeopardy situation.
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 the incident, discuss corrective actions, and provide recommendations.
- A performance improvement plan was developed and initiated based on root cause analysis as determined by the QAPI committee.
- Code blue drills were initiated on multiple shifts and ongoing drills will continue until all staff have completed and will continue with the 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. A posttest was provided upon completion of the education.
- 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 upon hire, or accepting a shift, 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 to reach completion for the identification of change condition with competency.