Failure to Initiate CPR for Full Code Resident
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to initiate cardiopulmonary resuscitation (CPR) for a resident who was documented as full code status. The resident, an elderly female with diagnoses including unspecified dementia and congestive heart failure, was under hospice care but had a clear physician's order and care plan indicating full code status. On the night of the incident, the resident was observed by a certified nursing assistant (CNA) to be breathing abnormally and was reported to the LVN, who assessed the resident and noted a faint pulse and imminent passing. The LVN left the bedside to verify the resident's code status, initially checking the hospice binder and then the electronic health record, which confirmed full code status. Despite confirming the resident's full code status, the LVN did not initiate CPR when the resident became unresponsive. Instead, the LVN instructed the CNA to perform post-mortem care. The LVN later stated that she was distracted by a personal emergency and mistakenly assumed that all hospice patients had do-not-resuscitate (DNR) orders, despite the documentation to the contrary. No vital signs were documented for the resident on the date of the incident, and emergency medical services were not contacted. The medical director confirmed that the expectation was for staff to follow physician orders, and that failure to do so could have impacted the resident's outcome. Interviews with facility staff, including the director of nursing (DON), CNA, and the administrator, confirmed that the LVN did not follow the established protocols for a resident with full code status. The facility's policies required that CPR be initiated for residents without a heartbeat or not breathing, in accordance with their advance directives and physician orders. The LVN's actions were inconsistent with these policies and the resident's documented wishes, resulting in the resident not receiving CPR prior to her death.