Failure to Initiate Immediate and Effective CPR for Full Code Resident
Penalty
Summary
A deficiency occurred when staff failed to initiate immediate and appropriate cardiopulmonary resuscitation (CPR) for a resident with a full code status who was found unresponsive. The resident, an elderly male with multiple significant diagnoses including end stage renal disease, dementia, severe sepsis, and metabolic encephalopathy, was noted to be dependent on staff for all activities of daily living and had severely impaired cognition. On the evening in question, the resident was last observed in the dining room and later found unresponsive, cold to the touch, with blue fingertips and signs of rigidity by two certified nursing assistants (CNAs). Upon discovering the resident's condition, the CNAs sought assistance from a registered nurse (RN), who appeared panicked and did not immediately initiate CPR. The RN left the room to verify the resident's code status and retrieve the crash cart, during which time no resuscitative efforts were started. When additional nursing staff arrived, chest compressions were eventually initiated, but not until several minutes had passed. The staff performing CPR were not all currently certified, and the compressions were described as ineffective by emergency medical services (EMS) personnel upon their arrival. No airway management or use of an automated external defibrillator (AED) was observed, and the resident was not placed on a hard surface for compressions. EMS personnel noted that the resident exhibited signs of rigor mortis and had likely been deceased for several hours prior to their arrival, despite staff statements regarding the last time the resident was seen alive. Facility policy required immediate initiation of CPR for residents with full code status, but this was not followed. The incident affected one resident directly, with the facility identifying 178 residents with full code status at the time of the survey.