Failure to Provide CPR to Full Code Resident
Penalty
Summary
A deficiency occurred when a resident with a documented full code status was not provided cardiopulmonary resuscitation (CPR) after being found unresponsive. The resident, who was cognitively intact and had a physician's order for full code, was discovered in their room by a CNA who reported the situation to an LPN. The LPN checked the resident's blood pressure, declared the resident dead, and instructed the CNA to clean the body without initiating a code or attempting CPR. No code was called, and no CPR was performed, despite the resident's full code status. The CNAs involved did not verify the resident's code status before proceeding with post-mortem care. One CNA assumed that because CPR had not been performed, the resident must have had a Do Not Resuscitate (DNR) order. Both CNAs described the resident's body as limp, with no significant discoloration or stiffness, and noted the presence of vomit and some blood. The LPN did not check the code status before instructing the CNAs to clean the body and later stated they believed the resident was on hospice and had a DNR order. The Assistant Director of Nursing (ADON) learned of the death via text message from the LPN and subsequently discovered that the resident was, in fact, a full code and not on hospice with a DNR. The ADON confirmed with the hospice service that there was no DNR in place. The failure to verify the resident's code status and to initiate CPR as required by facility policy and the resident's documented wishes led to the deficiency.
Removal Plan
- Facility QAPI members met to discuss the event, root cause, implementation of interventions, and auditing/compliance tools.
- DNR Binders are located at each nurse's station in the instance PCC is down for any reason.
- The ADON is responsible to update the binder for new admissions.
- The DON conducted chart audits regarding code status to ensure accuracy.
- The nurse was suspended pending further investigation and later terminated.
- Monitoring will be accomplished by the DON and/or designee auditing code status to ensure compliance.
- Any resident death that occurs in the facility will be reviewed to be sure code status was followed correctly.