Failure to Initiate CPR for Full Code Resident Due to Staff Misunderstanding
Penalty
Summary
Facility staff failed to assess and implement life-sustaining measures for a resident who was found unresponsive, despite the resident's advanced directives and physician orders specifying full code status and to attempt CPR. The facility's Emergency Response Management and Cardiopulmonary Resuscitation (CPR) policies required staff to initiate CPR in the event of cardiac or respiratory arrest for residents with full code status. The resident, who had diagnoses including cerebral atherosclerosis and was receiving hospice services, had a current POLST form and physician's order indicating that CPR should be attempted. On the day of the incident, the resident was noted by a CNA to be cold and not feeling well, and this was reported to the assigned LPN. Later, when the CNA returned to check on the resident, she found the resident cold and called for help. Multiple staff, including CNAs and LPNs, became aware that the resident was unresponsive and had no pulse or respirations. However, none of the nurses present checked the resident's code status or initiated CPR, as required by the resident's directives and facility policy. The DON later confirmed that staff mistakenly believed that hospice status implied a Do Not Resuscitate (DNR) order, despite documentation to the contrary. Interviews with staff revealed confusion during the shift change, with day and night shift nurses deferring responsibility to each other and not responding to the resident's room when alerted. The night shift LPN, upon being notified by a CNA, assessed the resident and confirmed the absence of vital signs but did not attempt CPR or verify code status. The failure to initiate CPR was not due to lack of policy or documentation, but rather staff assumptions and lack of verification regarding the resident's code status.