Failure to Initiate CPR for Full Code Resident
Penalty
Summary
Two registered nurses, the social services director and the interim director of nursing, failed to initiate cardiopulmonary resuscitation (CPR) for a resident who was found unresponsive, despite the resident being designated as Full Code/Full treatment. Upon discovery, the resident was pale, ashen, cool to the touch, had no visible movement, and was without a pulse. There was a significant amount of blood on the bed linens, and the resident was ultimately confirmed deceased. Staff present did not follow the facility's CPR policy, which required initiation of life-sustaining measures for residents with Full Code status. The resident had a history of cervical cancer, suspected to be stage IV with possible liver metastasis, and had experienced post-menopausal bleeding for several months prior to admission. Her care plan included an advanced directive specifying Full Code/Full Resuscitative measures in the event of cardiac arrest. Despite this, no life-sustaining measures were initiated by the immediate staff upon finding her unresponsive. Interviews revealed that staff were aware of her code status but made the decision not to start CPR, with one staff member stating that she did not want to "mutilate her body like that." Additional interviews indicated that some staff, including a CNA, had not received current CPR training, though all licensed nurses were required to be CPR certified. The facility's policy outlined that CPR should be initiated for residents with Full Code status unless specific conditions were present, such as dependent lividity or decomposition, which were not documented in this case. The failure to initiate CPR was a direct violation of both the resident's documented wishes and the facility's established policy.