Failure to Immediately Initiate CPR and Call 911 for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to immediately initiate CPR and promptly call 911 for a resident with a documented full code status who was found unresponsive and pulseless. The resident had multiple medical diagnoses, including type II diabetes, bradycardia, cerebral infarction, pulmonary hypertension, anemia, chronic respiratory failure, congestive heart failure, obstructive pulmonary disease, and sleep apnea, and had physician orders indicating full code. A CNA reported attempting to wake the resident around 4:30 a.m. and, when the resident did not respond, called a nurse. The nurse checked for a pulse, could not find one, and then left the room to verify the resident’s code status. After confirming the resident was full code, the nurse did not immediately initiate chest compressions and stated she did not know how to overhead page a code blue, prompting the CNA to get another nurse. Another nurse on the unit reported hearing the code blue page, seeing the agency nurse on the phone, and hearing other nurses question whether 911 had been called. One nurse stated she overhead paged the code and, upon arriving in the resident’s room, found no staff present, confirmed the absence of a pulse, and then started chest compressions. Another nurse from a different floor reported calling 911 herself because she was unsure if anyone else had done so and recalled that the agency nurse might have been calling another ambulance company instead of 911. The facility’s code blue policy requires the assigned nurse to initiate emergency interventions for full code residents after evaluating for cardiac arrest and to ensure 911 is called, and both the medical director and DON stated they expected immediate initiation of chest compressions for an unresponsive, pulseless full code resident. The American Heart Association guidance cited in the report emphasizes immediate high-quality CPR and prompt activation of emergency response as critical components of basic life support.
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