Failure to Provide CPR to Full Code Resident
Penalty
Summary
A registered nurse (RN) failed to provide basic life support, including CPR, to a resident who was found unresponsive and without vital signs. The resident had a documented full code status, as indicated in the care plan, physician orders, and admission notes. Despite this, the RN did not initiate CPR or arrange for emergency transport, instead contacting hospice and the resident's representative to report the death. The RN stated that she assumed the resident was a Do Not Resuscitate (DNR) because the resident was on hospice care, and did not verify the code status in the electronic medical record (EMR) before making this decision. The resident's representative, who was also the facility administrator, confirmed that there was no DNR on file and that the resident was a full code. The facility's policy required staff to provide CPR to residents with a full code status in the event of cardiac or respiratory arrest. Interviews with other nursing staff indicated that they were trained to check the code status in the EMR if a resident was found unresponsive. The failure to initiate CPR for a resident with a full code status constituted a failure to follow physician orders and facility policy regarding life-saving measures.