F0678

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Failure to Initiate CPR and Timely EMS Response for Full Code Resident

Cleveland, Ohio Survey Completed on 09-23-2025

Penalty

No penalty information released

Summary

A deficiency occurred when facility staff failed to initiate Cardiopulmonary Resuscitation (CPR) or promptly call Emergency Medical Services (EMS) for a resident who had advance directives indicating Full Code status. The resident, who had multiple significant medical diagnoses including chronic obstructive pulmonary disease, diabetes, heart failure, and was receiving hospice services, was found unresponsive. Despite the resident's documented wishes to receive all life-saving measures, no CPR was started by staff, and EMS was not called until nearly an hour after the resident was pronounced deceased.

At the time of the incident, the resident was under hospice care but had explicitly chosen to remain a Full Code, as documented in both the physician's orders and the care plan. Staff present at the scene, including an LPN and other aides, failed to recognize or act upon the resident's code status. The hospice nurse who arrived at the scene found the resident with no vital signs and confirmed death after auscultating for a heart rate for three minutes. The crash cart was not brought to the room until much later, and there was confusion among staff regarding the resident's code status and the appropriate emergency response.

Interviews and record reviews revealed that the LPN on duty did not know the resident's code status and did not initiate CPR. Other staff members, including another LPN and CNAs, were either unsure of the actions taken or did not participate in resuscitative efforts. Documentation was inconsistent, and there was evidence that staff attempted to retroactively document or misrepresent the provision of CPR. The facility's failure to follow established emergency procedures and to verify and act on the resident's code status resulted in the resident not receiving the life-saving interventions to which they were entitled.

Removal Plan

• Managerial staff, Regional Director of Clinical Services (RDCS) #601, the Administrator, and the DON reviewed data collaboratively, conducted a root cause analysis, and identified that LPN #521 did not know Resident #13's code status and did not initiate CPR.
• The Administrator and DON received education from President of Clinical Services (VPCS) #618 and President of Operations (VPO) #617 on where to locate advanced directives, CPR policy, Code Blue Flow Sheet, that hospice was not a code status and that advanced directives still need checked.
• Staff were educated to check the bed board, with a new process to add code status for staff and contracted service providers.
• Staff were educated to check the bed board, change of condition, communication during a code, the crash cart, and staffing assignments.
• An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held with management to review education on advanced directives, CPR policy, Code Blue Flow Sheet, hospice not being a code status, and the new bed board process.
• Contracted service providers would be educated to check the bed board, change of condition, communication during a code, crash cart, and staffing assignments.
• Each service provider would receive a memo upon entering the building stating the facility's new process, sign off on receipt and understanding, and memos would also be emailed to appropriate service providers.
• 32 Certified Nurse Aides (CNAs), 19 LPNs, four Registered Nurses (RN), seven housekeepers, six receptionists, 16 therapists, and 2 activity employees were educated on where to locate advanced directives, CPR policy, Code Blue Flow Sheet, hospice not being a code status, and the new bed board process.
• Contracted service providers will be educated to check the bed board, change of condition, communication during a code and crash cart, and staffing assignments by ADON #615 and the DON.
• A whole house audit for 58 residents' code status orders was reviewed for accuracy by ADON #615. This would be reviewed during clinical meetings, and the DON/designee would update and check the code status for new admissions.
• 58 resident care plans were reviewed for accuracy by MDS Coordinator #613.
• ADON #615 audited all current nurse's CPR certification records to ensure nursing staff had current CPR certification. No nurses were permitted to work until their active CPR certification was verified by Administration.
• Former Director of Nursing (FDON) #604 ran the audit report on 58 residents to assess for change of condition that was not addressed. No issues were identified. The DON/designee would audit the report.
• The DON and ADON #615 audited the three LPNs and four CNAs on duty and had them locate in the electronic medical record where the resident's code status was located.
• The DON/designee completed a mock code blue drill to identify areas of struggle.
• The Administrator, RDCS #601, and Regional Director of Operations (RDO) #599, administered a hands-on and written post-test for all nurses working.
• RDCS #601 and RDO #599 went to the units and demonstrated how to use the overhead page, how and where to look in the electronic medical record for code status, and how to use the walkie talkies. Staff performed a return demonstration of locating code status in the electronic medical record.
• An audit of the bed board code status would be reviewed and updated by the DON. Results of the audit would be reviewed through the facility's QAPI process.
• Mock code blue drills would be conducted on alternating shifts. Staff participating in the mock codes would document on the code blue documentation nurses note form. The mock codes would be overseen by the DON or designee. Results would be reviewed through the facility's QAPI process.
• A code blue drill would be conducted on alternating shifts. These audits would be completed by the DON or designee using the code response form.
• The DON or designee would begin auditing reports from the electronic medical record system to audit for any resident changes in condition, to ensure changes in condition were appropriately addressed. Results would be reviewed through the facility's QAPI process.
• Interview questionnaires would be conducted with first floor staff on how to obtain help during emergency situations on alternating shifts. These interviews would be conducted by the DON or designee. Results would be reviewed through the facility's QAPI process.
• The crash cart would be audited by the DON or designee to ensure all needed supplies are contained in the crash cart. The audits would take place on alternating shifts. Results would be reviewed through the facility's QAPI process.
• The DON or designee would audit the first-floor staffing, to ensure scheduled staff members are present as scheduled, on random shifts. Results would be reviewed through the facility's QAPI process.
• RDCS #601 provided additional one-on-one education to LPN #521 regarding what the Code Blue form is and when to utilize it. LPN #521 verbalized understanding.