F0678

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Failure to Promptly Assess and Initiate CPR for an Unresponsive Full-Code Resident

Los Angeles, California Survey Completed on 01-08-2026

Penalty

Fine: $9,430

Summary

The deficiency involves the facility’s failure to ensure staff promptly assessed and initiated CPR for a resident who was a documented full code. The resident had severe cognitive impairment, dysphagia, dementia, COPD, a feeding tube, and a POLST and physician order directing that CPR and full treatment be provided to prolong life by all medically effective means. On the day of the incident, a visiting family member of the resident’s roommate brought cookies into the room. After the roommate requested cookies, the visitor fed a cookie to the cognitively impaired resident without consulting staff, despite the resident being on a pureed diet and unable to safely swallow solid foods.

Shortly thereafter, the visitor observed the resident shaking, pale, and choking, and called for help. CNA1 responded and found the resident sitting up in bed, pale to bluish, with eyes open and wide, food running from the mouth, no movement, no gasping, no coughing, and no reaction to touch or to a finger sweep of the mouth. CNA1 reported that the resident did not blink, move, push back, or show any rise and fall of the chest. Despite recognizing these signs and being BLS certified (though her prior certificate was expired and her most recent certificate had been issued without her actually taking the class), CNA1 did not check for responsiveness in the prescribed manner, did not check for a pulse, and did not initiate CPR. Instead, she began performing the Heimlich maneuver two to three times and then, with RNA1, transferred the resident from the bed to a chair to continue the Heimlich.

RNA1 and LVN1 each entered the room after hearing that a patient was choking. Both acknowledged that they did not assess the resident for responsiveness or check for a pulse before performing or continuing the Heimlich maneuver. RNA1 stated he did not have time to check for a pulse and focused on positioning the resident and performing abdominal thrusts, first in bed and then in a chair. LVN1 stated she was told the resident was choking and immediately performed the Heimlich maneuver without checking for breathing or a pulse, later acknowledging that CPR may have been delayed because the pulse was not checked. Multiple staff, including CNA2 and the DON, observed the resident as unresponsive, pale, not moving, and not alert, yet none of the first responders checked the resident’s pulse or initiated CPR at that time.

RT1 arrived to find the resident sitting in a chair, appearing lifeless, not breathing, and without the universal sign of choking. RT1 checked the resident’s pulse, found none, and instructed staff to return the resident to bed and start CPR. Only at that point was CPR initiated. Interviews with the DON and Medical Director confirmed that facility policy and standard CPR protocols required that, upon finding an unresponsive resident, staff should immediately assess responsiveness, check for breathing and pulse, and, if no pulse is found, initiate CPR without delay. The facility’s own CPR policy required assessment of respirations and heartbeat, activation of emergency services, and initiation of CPR in the absence of a palpable pulse. The surveyors determined that CNA1, RNA1, and LVN1 failed to follow these required steps, resulting in a delay in CPR for a full-code resident who was unresponsive, not moving, and without a pulse when first found.

Removal Plan

• Implement a QAPI Performance Improvement Project (PIP) regarding CPR with return demonstrations.
• Educate all nurses on the procedure for initiating CPR and issue CPR certifications.
• Conduct CPR drills.
• Do not permit nurses to work without a CPR card until certification is completed.
• Audit residents' medical charts and identify residents who do not have a POLST.