Delayed CPR Initiation and Emergency Response for Full Code Resident
Penalty
Summary
Facility staff failed to provide timely emergency resuscitative efforts to a resident who was a Full Code, resulting in a ten-minute delay before CPR was initiated. The resident, who had multiple complex medical diagnoses including sepsis, COPD, heart failure, and diabetes, was found unresponsive in bed by CNAs during morning care. Initial assessment by staff revealed no pulse, no oxygen saturation, no blood sugar, and no measurable blood pressure. Despite the resident's documented Full Code status, no immediate CPR was started by the CNAs or the first LPNs who assessed the resident. Instead, staff left the room to seek verification of the code status and to find additional staff, further delaying the initiation of life-saving measures. Multiple staff members, including CNAs and LPNs, entered the resident's room, assessed the resident, and determined there were no signs of life, but none initiated CPR at that time. The DON was eventually called to the room, and only after confirming the code status as Full Code did the DON and other staff begin CPR, approximately ten minutes after the resident was first found unresponsive. During this period, 911 was not called immediately, and resuscitative efforts were not started as per facility policy, which states that CPR should be initiated immediately if code status is unclear and continued until EMS arrives or a physician provides further instruction. Interviews with staff revealed a lack of prompt assessment and action regarding the resident's change in condition, as well as uncertainty and delays in verifying code status. The night nurse did not report the resident's abnormal condition to management or the physician, and day shift staff did not check on the resident promptly despite being informed the resident was not feeling well. The facility's failure to initiate CPR immediately upon finding the resident unresponsive, and the delay in calling emergency services, directly contributed to the deficiency cited by surveyors.
Removal Plan
- The facility implemented a revised Cardiopulmonary Resuscitation (CPR) policy to instruct staff to call emergency services (911) earlier in the CPR process.
- All facility direct care personnel have been educated to ensure they are aware of the policy related to change of condition assessment, immediate initiation of CPR, and identification of the location where the resident's code status is documented.
- A new ‘acknowledgement' form was introduced for all new employees to sign, indicating they have been trained on the facility CPR policy and where to find a resident's code status.
- Training on location and identification of code status began and will continue with any new staff hired or staff categorized as ‘As needed.’
- Facility management staff received education on the updated CPR policy and procedures.
- Direct care floor staff were trained on the updated CPR policy and procedures.
- The facility updated their CPR policy to incorporate effective CPR procedures for residents who have chosen to be fully resuscitated.
- Every resident chart was reviewed and reconciled with the resident Physician Order Sheet (POS) and face sheet to ensure any resident who chooses to be a ‘Full Code’ has that information easily accessible to staff.
- A Quality Assurance Performance Improvement (QAPI) meeting was held to discuss change of condition assessment, initiation of CPR, and to review policies and procedures.
- Facility staff reviewed 100% of resident charts to ensure proper orders are in place and appropriate chart identification for advanced directives.
- The Interdisciplinary Team (IDT) will continue with reeducation of change of condition assessment, reporting, and initiation of CPR, with education offered for one year, annually, and upon hire.