Delay in Initiating CPR for Full Code Resident
Penalty
Summary
Licensed staff failed to ensure that cardiopulmonary resuscitation (CPR) was provided immediately when a resident was found unresponsive. The resident, who had diagnoses including gram-positive bacteremia, Parkinson's disease, seizure disorder, and difficulty walking, was documented as a full code in both physician orders and the care plan, indicating that all life-saving measures, including CPR, should be performed in the event of cardiac or respiratory arrest. The care plan specifically stated that the resident's code status should be honored and that CPR should be initiated in the event of a code. On the day of the incident, a CNA discovered the resident unresponsive, face down, and not breathing, with no visible or audible signs of life. The CNA did not call for help from within the room but instead left to find a nurse. The LPN who responded also found the resident unresponsive and without a pulse, and instructed the CNA to get the RN and to call 911. CPR was not initiated until the RN arrived and, with assistance, repositioned the resident to the floor. The RN then began chest compressions, and the LPN provided breaths with an Ambu bag. The delay in starting CPR was confirmed by interviews and documentation, as CPR was not started until after the RN entered the room and the resident was repositioned. Facility policy required that staff check for responsiveness, breathing, and pulse, call for help, activate emergency response, and start CPR immediately if no pulse or breathing was detected. Interviews with facility leadership confirmed that the expectation was for CPR to be started as soon as possible, in accordance with policy and the resident's full code status. The delay in initiating CPR was contrary to these expectations and the facility's written procedures.