Failure to Provide Effective CPR and Verify Code Status
Penalty
Summary
A deficiency occurred when facility staff failed to provide basic life support, including effective CPR, to a resident who was documented as a full code. The resident's medical records, advance directive, and physician's order all indicated that the resident had chosen to have CPR performed if required. On the date of the incident, the resident was found unresponsive, and a code was called. Staff began chest compressions while the resident was lying on a mattress, but did not use a backboard, which is necessary to ensure effective compressions on a soft surface. Additionally, no rescue breaths were provided using an Ambu bag or face shield, despite facility policy requiring ventilations with a compression-ventilation ratio of 30:2. During the code, confusion arose among staff regarding the resident's code status. Some staff members stopped CPR after being told by hospice that the resident was a DNR, even though facility records indicated the resident was a full code. This led to a period where CPR was halted until emergency medical technicians (EMTs) arrived, confirmed the resident's full code status, and resumed CPR. Interviews with staff revealed inconsistent accounts of who performed CPR, whether it was continuous, and whether appropriate equipment and techniques were used. Several staff members were unaware of the availability or purpose of a backboard, and none reported providing rescue breaths prior to EMT arrival. Facility documentation and staff interviews confirmed that the crash cart, which contained an Ambu bag, was present in the hallway, but staff did not utilize it for providing ventilations. The investigation also found that staff were unable to definitively identify the resident's code status during the emergency, resulting in the withholding of CPR for a resident who had requested it. The lack of effective CPR, including the absence of a backboard and rescue breaths, and the failure to verify and act on the resident's code status, constituted the deficiency.
Removal Plan
- All staff were in-serviced on code status, crash carts, code leader, CPR, and mock codes.
- A system to identify staff trained in CPR was put in place.
- Staff training on how to identify a resident's code status was completed.
- Members of the QAPI team met regarding CPR, mock codes drills, code status accuracy, verification with hospice providers, system review, post code briefings, and investigation completion.