Delayed CPR Initiation for Full Code Resident
Penalty
Summary
Facility staff failed to initiate cardiopulmonary resuscitation (CPR) in a timely manner for a resident who was found unresponsive, pulseless, and not breathing. The resident had a documented status as a full code, with clear physician orders and a POLST form indicating that all life-sustaining treatments, including CPR, were to be attempted in the event of cardiac arrest. Despite this, staff did not begin CPR for approximately 10-20 minutes after the resident was discovered in bed without vital signs. Multiple staff interviews and record reviews revealed that certified nursing assistants (CNAs) discovered the resident unresponsive and immediately notified the registered nurse (RN) on duty. The RN, however, responded slowly, initially dismissed the urgency, and did not promptly check the resident’s code status or initiate CPR. Other staff members, including another RN and LPN, were eventually involved, but only after a significant delay and after being reminded by oncoming staff that the resident was a full code. During this period, staff began preparing the resident for post-mortem care, believing the resident had expired, until the code status was clarified and CPR was finally started. Documentation and staff statements confirm that the delay in initiating CPR was due to the RN’s inaction and lack of leadership, as well as a lack of immediate recognition and response to the resident’s code status. The facility’s policy required immediate emergency care and CPR in accordance with the resident’s wishes, but this was not followed. The failure to provide timely CPR resulted in the resident being without resuscitative efforts for an extended period before emergency medical services arrived and transported the resident to the hospital, where death was pronounced shortly after arrival.
Removal Plan
- Facility administrator and DON were in-serviced by the regional nurse on the emergencies policy 3.06 regarding cardiac arrest and CPR.
- DON initiated and completed in-servicing with all nursing staff on the emergencies policy 3.06 regarding cardiac arrest and CPR.
- DON initiated and completed in-servicing with all nursing staff on location of code status/POLST for residents.
- Plan was added to the facility QA program regarding CPR and code status.
- The facility DON or designee will audit employees to ensure that location of code status/POLST is known and understanding of the emergencies policy.
- This will remain as part of the facility QA process for continued monitoring.