Failure to Provide Appropriate CPR and Emergency Response for Full Code Residents
Penalty
Summary
The facility failed to provide appropriate care for acute changes in condition for two residents who were full code and subsequently died. In the first case, a resident with multiple complex medical conditions, including end-stage renal disease, congestive heart failure, and chronic respiratory failure, was found unresponsive by a CNA. The RN assessed the resident, found no pulse or vital signs, and initiated chest compressions. However, the RN performed only three rounds of compressions, did not provide rescue breathing, and stopped CPR before EMS arrived, contrary to both facility policy and American Heart Association (AHA) guidelines, which require continuous CPR with compressions and ventilations until advanced help arrives or the resident is pronounced dead by a physician. The RN stated she learned the method of three rounds of compressions from a journal, and the LPN who assisted did not provide rescue breathing either. EMS arrived to find the resident cold, pulseless, and with rigor mortis, and did not initiate further resuscitation. In the second case, another resident with significant comorbidities, including heart failure, COPD, and dependence on dialysis and supplemental oxygen, was found unresponsive by a CNA. The nurse assessed the resident, confirmed the absence of pulse and breathing, and called a code. Staff responded, chest compressions were initiated, and the AED was applied. However, no ventilations were provided during CPR because the crash cart was missing an Ambu bag, which is required for providing manual ventilation. Multiple staff members noted that one LPN was performing compressions incorrectly over the left breast instead of the sternum, and other staff had to take over. The AED advised no shock, and CPR continued until EMS arrived and took over, but the resident could not be revived. Interviews revealed that the crash cart was not fully stocked as required, and staff were unaware of the missing Ambu bag until the code event. Both incidents demonstrated failures to follow established CPR protocols and facility policies, including the requirement for continuous compressions and ventilations for full code residents, proper stocking of emergency equipment, and correct technique during resuscitation. Staff interviews and documentation confirmed that these deficiencies occurred, and that the facility's policies and AHA guidelines were not followed during the response to both residents' acute changes in condition.