Failure to Initiate CPR for Full Code Resident
Penalty
Summary
Licensed staff failed to provide basic life support, including CPR, to a resident who was found unresponsive and without vital signs. The resident had a documented code status of Full Code, as indicated in the medical record, hospice documentation, and a POLST form signed by the resident's representative. Despite this, when the resident was discovered unresponsive, nursing staff did not initiate CPR or call a Code Blue, and no resuscitation efforts were made prior to the arrival of hospice personnel, who subsequently pronounced the resident deceased. The resident had multiple significant diagnoses, including chronic obstructive pulmonary disease, dementia, hypertensive heart disease with heart failure, and was under hospice care. The code status was discussed and confirmed with the resident's representative, who wished for all life-saving interventions to be performed. The facility's own policy required staff to provide basic life support in the absence of a valid DNR order, and the staff were aware of the resident's Full Code status. Interviews with the Director of Staff Development, a licensed nurse, and certified nursing assistants confirmed that no CPR was attempted, and the facility's emergency response protocol was not followed. Staff interviews revealed a lack of clarity and adherence to protocol, with the nurse on duty stating she did not know the facility's procedures and had concerns about reviving the resident. The Director of Nursing confirmed that the facility's policy was not followed and that the decision to perform CPR was not up to the nursing staff, as the representative's wishes were clearly documented. The failure to initiate CPR resulted in the resident's representative's wishes not being honored and potentially contributed to the resident's death.