Failure to Initiate CPR Due to Inadequate Code Status Documentation
Penalty
Summary
The facility failed to initiate cardiopulmonary resuscitation (CPR) for a resident in accordance with physician orders and the resident’s code status. The resident was admitted with multiple diagnoses, including hypertensive crisis, likely acute intracranial hemorrhage, left PCA occlusion, dementia with word-finding difficulties, and ambulatory dysfunction. Documentation revealed that the resident’s Medication Administration Record (MAR) indicated a full code status, but this was not reflected on the face sheet or care plan. When the resident was found unresponsive, staff did not initiate CPR, and the nurse documented that a Do Not Resuscitate (DNR) order was confirmed, despite the absence of such documentation in the medical record. Interviews with facility staff revealed confusion and inconsistency regarding the resident’s code status. The Director of Nursing (DON) and other staff members indicated reliance on information from the hospital and verbal statements from the resident’s daughter, but there was no documented discussion or signed DNR in the facility’s records. The nurse practitioner and other staff described challenges with entering code status into the electronic medical record and uncertainty about the process for confirming and documenting code status upon admission. The social services director also confirmed that there was no opportunity to speak with the resident or family about advance directives prior to the incident. The lack of clear documentation and communication regarding the resident’s code status led to the failure to provide basic life support as required by physician orders. The facility’s policies required that advance directives be respected and documented, but these procedures were not followed, resulting in the omission of CPR for a resident who was, according to available orders, a full code. This deficiency was determined by the survey team to constitute substandard quality of care and was cited under 42 CFR 483.24 – Quality of Life.
Removal Plan
- Administrator notified the Medical Director of Immediate Jeopardy.
- Social Service Director initiated an audit on Code Status for all new admissions.
- All code binders in all cottages audited to ensure they match orders in PCC.
- Social Service Director initiated an audit on Code Status for all other residents and audited code binders in all cottages to ensure they match orders in PCC.
- New admission's code status and code books will be audited.
- Social Service Director initiated an audit on Advanced Directive to determine if conversations with resident and/or responsible representative held at time of admissions for all new admissions.
- New admissions will be audited to ensure education offered on Advance Directives and code status honored.
- Education provided by the Assistant Regional Director of Clinical Services and Regional President of Operations to Administrator, Director of Nursing, Assistant Director of Nursing, and Social Service Director on conversations with resident and/or responsible representative for Advanced Directives upon admission.
- Education conducted as a review of facility policy and procedure in regard to Advanced Directives with resident and/or responsible representative upon admission.
- Education initiated by Director of Nursing and/or designee to all licensed nurses related to education resident and/or responsible representative on Advanced Directive and code status upon admission.
- All staff (including any agency-assigned staff) that have not completed education will not be permitted to work until education is completed.
- Director of Nursing and/or designee-initiated education for all nursing staff on Code Blue policy and procedures.
- Director of Nursing initiated an audit on Code Status accuracy and Advanced Directives on all resident Care Plans.
- Care plans will be audited to ensure code status is accurate.