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Failure to Initiate CPR for Full Code Resident

Minneapolis, Minnesota Survey Completed on 09-03-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to follow the Provider Orders for Life Sustaining Treatment (POLST) for a resident who had elected to be a full code, meaning they wished to receive cardiopulmonary resuscitation (CPR) in the event of cardiopulmonary arrest. The resident, who had diagnoses including metabolic encephalopathy, type 2 diabetes, and end stage renal disease, was also on hospice care but had clearly documented wishes and provider orders for full resuscitation efforts. When the resident was found unresponsive and not breathing, staff did not check the resident's code status and did not initiate CPR, despite the absence of a pulse and respirations. Multiple staff interviews confirmed that the standard procedure was to check a resident's code status and initiate CPR if consistent with the resident's wishes, regardless of hospice status. However, in this incident, both the LPN and the hospice nurse present failed to verify the code status or begin resuscitation efforts. The time of death was called without any attempt at CPR, and the resident's body was prepared for the mortuary without further intervention. Documentation in the resident's progress notes also lacked any reference to checking code status or attempting CPR. The facility's policy required staff to provide basic life support, including CPR, in accordance with the resident's advance directives unless there were obvious signs of clinical death, which were not present in this case. The DON confirmed that the resident's code status was not checked and that CPR was not performed, which was inconsistent with both facility policy and the resident's documented wishes.

Removal Plan

  • LPN-A was immediately suspended and communication with hospice company occurred.
  • House-wide nurse education started including the importance of checking a resident's code status when they were found unresponsive and not breathing, including residents who had elected hospice care. Education completed.
  • Nurse STAT (Code Blue) drills started. Drills included residents who were full code, DNR, and hospice residents.
See complete original report
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