Failure to Initiate Immediate CPR for Unresponsive Resident
Penalty
Summary
The facility failed to provide immediate basic life support, including CPR, to a resident who was found unresponsive and without a pulse in the dining room. Surveillance footage showed that after the resident was discovered, staff did not initiate CPR at the scene. Instead, a certified nurse aide alerted a licensed practical nurse, who then left the dining room to check for the resident's code status. Upon confirming the resident was a Full Code, staff decided to move the resident from the dining room to their room before starting chest compressions. During this time, other staff members were observed entering the dining room, making phone calls, and retrieving the crash cart. Emergency Medical Services were called and arrived several minutes later, at which point the resident was pronounced deceased. The facility's policy required immediate initiation of CPR by certified staff unless a do not resuscitate order was present, which was not the case for this resident. Interviews with staff and the Director of Nursing confirmed that CPR should have been started immediately at the point of care, but this did not occur. The delay in initiating CPR was due to staff leaving the area to check documentation and moving the resident to another location before starting resuscitation efforts.