Failure to Provide CPR to Full Code Resident on Hospice
Penalty
Summary
A deficiency occurred when facility staff failed to provide basic life support, including CPR, to a resident who was designated as full code and required emergency care prior to the arrival of emergency medical personnel. The resident, an elderly female with severe cognitive impairment, multiple chronic conditions including dementia, polyneuropathy, chronic kidney disease, and was on hospice care, was found unresponsive by staff. Despite her full code status, no life-saving measures were initiated. The resident's care plan and medical records clearly indicated her full code status, and facility policy stated that hospice enrollment does not automatically change a resident's code status. However, the LVN on duty assumed the resident was a DNR due to her hospice status and did not attempt CPR. The LVN reported relying on information from the CNA and was not familiar with the resident, as it was her first time working with her. The administrator confirmed that the LVN did not perform CPR and reiterated that CPR was expected for full code residents, regardless of hospice enrollment. Interviews with staff revealed a lack of awareness and understanding regarding code status identification and the distinction between hospice care and DNR orders. The facility's failure to verify and act according to the resident's documented code status resulted in the omission of basic life support measures. This event was identified as Immediate Jeopardy due to the failure to provide required emergency care to a resident with a full code status.
Removal Plan
- Nursing staff and agency personnel received re-education from the DON on the proper procedure for locating a resident's code status within the electronic medical record.
- All nursing staff and agency personnel will receive in-service training.
- The Chief Executive Officer in-serviced the DON on the proper procedure for locating a resident's code status within the electronic medical record.
- The DON in-serviced the ADON on locating residents code status on electronic medical record.
- A comprehensive audit of each resident's code status was completed to ensure accuracy and compliance with facility policy.
- Nursing staff and agency personnel were re-educated on emergency response procedures and initiating CPR for any Full Code resident without signs of life.
- Staff and agency personnel received education regarding the meaning of the red and green markers on each resident's door to indicate code status.
- A Performance Improvement Plan was put in place for trend analysis and system improvement.