Failure to Ensure Immediate CPR and Maintain Crash Cart Readiness
Penalty
Summary
The facility failed to ensure that basic life support, including CPR, was initiated immediately and according to policy for a resident who experienced an unexpected death. The facility did not have a clear, written policy or protocol outlining the procedures, documentation expectations, or staff responsibilities during a cardiac or respiratory arrest event. Staff interviews revealed confusion regarding who was responsible for initiating CPR, how to verify code status, and how to call a Code Blue. There were also inconsistencies in staff statements about the sequence of events, with delays in recognizing the resident's unresponsiveness, checking for a pulse, and notifying a nurse. Additionally, some staff members were not current in their CPR certification, and there was uncertainty about whether nursing assistants could initiate CPR if they were certified and knew the resident's code status. The facility's crash carts were not consistently stocked with required, unexpired supplies and equipment necessary for immediate use during a code event. Observations showed missing or expired items such as blood glucose test strips, non-rebreather masks, oral airways, and oxygen tanks that were not full. There were discrepancies between different crash cart checklists, leading to confusion about what items should be present and how equipment should be set up. Some crash carts lacked essential documentation forms, and daily checks were not consistently documented or performed as required. The facility also had an AED that was not readily accessible or in a designated location for emergency use. The system for maintaining and accessing residents' Physician Orders for Life-Sustaining Treatment (POLST) was disorganized and unreliable. POLST forms were missing, filed under incorrect room numbers, or not updated to reflect residents' current locations. There were inconsistencies between posted code status lists and the actual POLST forms in the binders. Staff were unclear about where to find residents' code status information, with some relying on electronic records, binders, or posted lists, and others unsure of the process. These failures placed numerous residents with current POLSTs requesting CPR at serious risk for adverse outcomes.
Removal Plan
- Audited the records of all residents
- Audited the POLST binders
- Audited and stocked the crash carts
- Updated the facility CPR policy
- Educated staff on the facility's CPR Policy and Code Blue Emergency process during CPR
- Audited and ensured licensed staff had current CPR training
- Implemented a plan of correction to sustain ongoing compliance