Failure to Ensure Nursing Staff Competency in Code Status Identification and Timely CPR Response
Penalty
Summary
Nursing staff failed to demonstrate competency in identifying a resident's code status, providing timely CPR, and responding appropriately to a change in condition for one resident. The resident, who had multiple complex diagnoses including metabolic encephalopathy, multiple sclerosis, sepsis, acute respiratory failure with hypoxia, and was cognitively intact, experienced a significant drop in oxygen saturation to 84% while on supplemental oxygen. Despite this abnormal reading, the LPN on duty did not notify the medical provider or document any interventions regarding the change in condition. Later, the resident was found pulseless and not breathing. There was confusion among the nursing staff regarding the resident's code status due to conflicting documentation between the hospital transfer form, which indicated DNR, and the facility's electronic health record and care plan, which indicated full code. The LPN and other staff delayed initiating CPR while attempting to clarify the code status, consulting with the DON and other supervisors, and paging hospice. This resulted in a delay of 45-60 minutes before chest compressions and ventilation were started, during which time the resident's wishes for CPR were not honored, and the resident died. Further review revealed that the LPN involved had incomplete orientation records, with no documentation of training on advanced directives, DNR orders, hospice care, respiratory care, vital signs, or change in condition protocols. The facility was unable to confirm whether another LPN had received the required training. Interviews with staff and review of facility policies indicated that prior to the incident, there was a lack of consistent staff training on code blue drills, advanced directives, and change in condition response, contributing to the deficiency.
Removal Plan
- An audit of each resident's code status was initiated and completed.
- The licensed nurse was suspended, pending investigation.
- An ADHOC 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 initiated on multiple shifts and will continue until all staff have completed, 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.
- 100% of 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.
- The Human Resource Director will ensure during new hire orientation, newly hired nurses and CNAs are educated on the facility policy related to advanced directives, CPR, and the completed road map from orientation will be signed acknowledging the education received.
- 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.