Failure to Initiate CPR for Full Code Resident
Penalty
Summary
A deficiency occurred when nursing staff failed to initiate cardiopulmonary resuscitation (CPR) for a resident who was found unresponsive, despite the resident having a documented full code status. The assigned agency RN did not perform CPR upon discovering the resident unresponsive and without vital signs, and instead pronounced the resident deceased. The nurse stated she was informed the resident was on hospice and did not recall the code status, leading to no resuscitative efforts being made. Other staff, including CNAs, were aware of the resident's full code status and expected that CPR should have been started, but no action was taken to initiate a code or call emergency services. The resident involved had a history of hereditary ataxias, dysphagia following cerebral infarction, and Parkinson's disease, and was admitted to hospice services with a clear advance directive indicating full cardiopulmonary resuscitation. Despite this, the care plan did not document the code status or advance directives, and the nurse relied on verbal information about hospice status rather than verifying the resident's documented wishes. The nurse did not check the medical record or care plan for code status before deciding not to initiate CPR. Interviews with staff revealed a lack of clarity and communication regarding the resident's code status, with some staff assuming hospice status equated to a do-not-resuscitate (DNR) order. The facility's policies required CPR to be initiated for full code residents unless a DNR order was present and documented. The failure to follow these policies and verify the resident's code status resulted in the resident not receiving basic life support prior to death.
Removal Plan
- All resident charts were audited to confirm code status based on Resident/POA wishes.
- Facility licensed staff were provided with in-service education. Education included ensuring CPR was initiated for residents identified as full codes, a resident on hospice does not mean DNR code status, location of code status preference in resident records, and review of facility cardiac arrest emergency management policy.
- Agency licensed staff were provided with in-service education. Education included ensuring CPR was initiated for residents identified as full codes, a resident on hospice does not mean DNR code status, location of code status preference in resident records, and review of facility cardiac arrest emergency management policy.
- The Director of Nursing will ensure that all staff received in-service education and completed education was documented prior to working their next assigned shift.
- The Director of Nursing/Designee will monitor all booked shifts for Agency licensed staff for completion of assigned required in-service education and completed education was documented prior to working the scheduled shift.
- The medical director was notified.
- The Director of Nursing held mock CPR drills with nursing staff on each shift.
- Director of Nursing will conduct mock CPR drills monthly on each shift.
- Information from the drills will be reviewed for recommendations at QA&A committee meetings monthly.
- An Ad-Hoc QAPI meeting was held to review findings and action plan.