Failure to Provide CPR Due to Code Status Confusion and Staff Errors
Penalty
Summary
Facility staff failed to provide cardiopulmonary resuscitation (CPR) to a resident who was documented as a Full Code in multiple locations, including the care plan, physician orders, Medication Administration Record (MAR), and Electronic Health Record (EHR). Despite clear documentation of the resident's wishes and physician orders to initiate CPR in the event of cardiac arrest, staff did not carry out resuscitative efforts when the resident was found unresponsive. The failure was due to discrepancies in code status indicators, such as incorrect or missing stickers on the resident's door following a room change, and staff misreading the resident's chart. On the day of the incident, several staff members responded to the resident, who was found slumped in a recliner, diaphoretic, unresponsive, and later displaying agonal respirations. Staff were directed to call 911, verify code status, and obtain the crash cart. However, there was confusion and delay in verifying the resident's code status, with staff incorrectly identifying the resident as a Do Not Resuscitate (DNR) based on misinterpretation of chart information and door stickers. During this period, staff did not initiate CPR, and the resident was pronounced deceased. The ARNP was informed of the death and, based on the incorrect report of DNR status, gave an order to release the body. Multiple staff interviews revealed that the confusion was compounded by staff unfamiliarity with the location of the crash cart and failure to promptly call 911. Staff later discovered, upon further review of the resident's records, that the resident was in fact a Full Code. The deficiency was attributed to miscommunication, lack of familiarity with emergency procedures, and errors in identifying the correct code status, resulting in the failure to provide basic life support as required by the resident's wishes and physician orders.