Delay in CPR Initiation Due to Unclear Code Status Documentation
Penalty
Summary
The facility failed to prevent a delay in care when a resident was found unresponsive. According to the facility's policy, if a resident's Do Not Resuscitate (DNR) status is unclear, CPR should be initiated until a DNR or physician's order is confirmed. In this incident, the resident had a care plan indicating full code status and a wish to have CPR performed. However, when the resident was found unresponsive, staff were initially unsure of the resident's code status because it was not listed in the electronic health record under the resident's name. Staff had to consult the resident's Kardex to determine the code status, which led to a delay in initiating CPR. Nursing notes indicated that the resident was found unresponsive with no respirations, pulse, or heart sounds. Although CPR was eventually started and continued until emergency services arrived, the EMS report showed that the facility did not start resuscitation efforts prior to their arrival. The EMS was called at 5:06 a.m. and arrived at 5:12 a.m., but the timeline provided by staff interviews suggested that CPR may have only been started around the time EMS arrived, rather than immediately upon finding the resident unresponsive. Interviews with staff revealed confusion and lack of clarity regarding the process for determining a resident's code status, as well as the timing of when CPR should be initiated. The Assistant Director of Nursing (ADON) and Certified Nursing Assistants (CNAs) confirmed that the code status was not readily available in the electronic health record at the time of the incident, contributing to the delay in care. The deficiency was identified as an Immediate Jeopardy situation due to the failure to provide timely basic life support to a resident who was a full code.
Removal Plan
- Review all residents' code status, update electronic records, and update care plans.
- Maintain a list of all residents' current code status at each nurse's station.
- In-service all staff on calling 911 when a resident is found unresponsive regardless of code status and maintain a resident code status list at each nurse's station.
- In-service all licensed nurses on initiating CPR on any resident that is a full code and continuing until emergency services arrive.
- Make any employee who cannot be reached for in-service inactive and remove from the schedule until education is provided.