Failure to Initiate Timely CPR for a Full Code Resident on Hospice
Penalty
Summary
The deficiency involves the facility’s failure to provide timely CPR to a resident who had clearly documented Full Code status. The resident was admitted with multiple diagnoses including atherosclerotic heart disease, generalized anxiety disorder, atrial fibrillation, and chronic kidney disease, and had intact cognition per a recent MDS. The resident’s care plan, EMR profile sheet, physician orders, and a recent physician progress note all documented the resident as Full Code, and the care plan directed staff to ensure the resident’s wishes regarding advanced directives were honored and reviewed at least quarterly and with any change in condition. On the day of the incident, the resident was on hospice services and had been declining since around midnight, with hospice and family present much of the day. Shortly before the event, the resident exhibited Cheyne-Stokes respirations and cool skin, and received a dose of morphine from a hospice nurse. At approximately 5:10 p.m., a family member informed a nurse that the resident may have passed. The nurse assessed the resident and documented no audible heart sounds or respirations, but did not check the resident’s code status at that time and did not initiate CPR, despite the resident’s documented Full Code status. Over the next 45–66 minutes, multiple staff interactions occurred without CPR being started. The nurse contacted a consultant nurse, and hospice was notified and en route. Administrative and consultant nurses later questioned and confirmed the resident’s code status as Full Code in the EMR. Only after being prompted by the hospice nurse and another nurse, and after confirmation of Full Code status by administrative staff, did the involved nurses return to the room and initiate CPR, at approximately 6:10–6:16 p.m. EMS arrived shortly thereafter and pronounced the resident deceased. The lapse between the initial notification of the resident’s presumed death and the initiation of CPR constituted the failure to provide basic life support to a Full Code resident, which surveyors determined placed the resident and all Full Code residents in immediate jeopardy.
Removal Plan
- Suspended the two nurses involved (LN I and LN G) pending investigation (LN G later terminated).
- Completed training for all licensed staff on the advanced directive policy and how to identify a resident's code status in the EMR (signature sheets on file).
- Required all licensed staff to complete the training before working.
- Conducted interviews of nurses by the DON or designee regarding procedures when a resident is found unresponsive and how to identify code status.
- Scheduled mock reviews/audits of checking resident code status (audits on file).
- Reported patterns or trends to the Quality Assurance committee for recommendations and follow-up.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.