Failure to Initiate Timely CPR and Improper Code Status Handling for a Full Code Resident
Summary
The deficiency involves the facility’s failure to provide timely emergency medical care and CPR to a resident who had a documented full code status. The resident was an adult male admitted with malignant neoplasm of the tonsil and lymph node, dysphagia, and pneumonitis, and had an advance directive and physician order indicating “Full Resuscitate.” His BIMS score showed intact cognition, and he had signed a CPR consent form requesting resuscitation in the event of cardiac arrest. Therapy and rehabilitation documentation indicated he had good rehab potential and personal goals to walk again and relocate, and staff, including the Director of Rehabilitation and a Nurse Practitioner, later stated they were surprised by his death. On the morning of the incident, a CNA entered the resident’s room to obtain vital signs and found him unresponsive, appearing not to be breathing and not responding to touch or name. The CNA immediately alerted the RN assigned to the hall, who was at the medication cart. The CNA reported that the RN initially responded verbally from a distance, then took approximately two minutes to secure medications before going to the room. Upon arrival, the RN assessed for a pulse at the wrist and ankle, concluded the resident had passed, and covered him completely with a sheet. The RN then left the room to retrieve a stethoscope from the medication cart, administered another resident’s medications, and later returned to listen for an apical pulse and again covered the resident, without initiating CPR or calling a code blue at that time. The RN stated she did not know the resident’s code status during this initial assessment and believed the resident was “very cold and very dead,” and reported observing mottling of the legs. Subsequently, another RN on a different unit learned there had been a death and questioned the situation. This RN asked the first RN for the resident’s code status and observed that the chart being referenced was for a different patient. After directing the first RN to the correct chart, the second RN identified the resident as full code and instructed that CPR be started, a code blue be called, and 911 be contacted. When the second RN entered the room, the resident was fully covered with a sheet, pulseless, and not breathing, but without observed rigor mortis, lividity, or mottling, and not recalled as cold to the touch. CPR and BVM ventilation were initiated, and multiple nurses and CNAs responded to the code. During the code, the first RN contacted the DON by phone; staff in the room reported that the first RN entered and instructed them to stop CPR, stating the DON had ordered it, although the DON later denied giving an order to stop and stated that for a full code, staff were to run the code until EMS arrived or a physician order was obtained. Another nurse recalled the first RN saying she thought the resident had been dead for a couple of hours. During the resuscitation efforts, the first RN also contacted an on-call provider and requested a change in the resident’s code status to DNR because imminent death was suspected. A PA documented being notified that the resident had passed away and that CPR had been started, and recorded that the code status changed to DNR. When questioned later, both the RN and the PA were unable to explain how the code status could be changed from full code to DNR without the resident’s consent and without the statutory requirements for a DNR order being met. A Nurse Practitioner stated that such a change was impossible without the declarant’s signature, a physician signature, and two witnesses, and that qualified staff were obligated to perform CPR on full code residents until an order to stop was received from an on-site physician or medical control. Multiple staff, including a CNA who was a CPR instructor, indicated that too much time elapsed between finding the resident unresponsive and initiating CPR. The facility’s own CPR/BLS policy and the American Heart Association BLS algorithm, as cited in the report, required initiation of CPR for a pulseless, non-breathing full code resident in the absence of obvious signs of irreversible death, which were not consistently observed or documented by responding staff. The Immediate Jeopardy was determined to have begun when the RN first found the resident without pulse or respirations and failed to initiate emergency life-sustaining measures despite his full code status, and the resident was later pronounced dead by a hospital physician. Interviews and record review documented conflicting accounts regarding the resident’s physical condition (coldness, mottling, and signs of irreversible death), the timing of assessments and interventions, and the communication between the RN, DON, and on-call provider about stopping CPR and changing code status. Staff statements consistently described a delay in initiating CPR, initial misidentification of the resident’s code status, and the resident being fully covered with a sheet before a code was called, all in the context of a documented full code order and signed CPR consent. The report also cites state law requirements for executing a DNR order, including that an individual of sound mind or a patient advocate may execute a DNR, and that the order must be dated, voluntary, and signed by the declarant or patient advocate, the attending physician, and two witnesses. These statutory requirements were contrasted with the events in which the resident’s code status was documented as changed to DNR during or immediately after the code, based solely on nursing staff communication to the PA, without evidence of the required signatures or the resident’s participation. Facility policy required staff to provide basic life support, including CPR, for full code residents who did not show obvious clinical signs of irreversible death, and to coordinate rescue efforts until EMS arrival, but the actions described in the report show that these procedures were not followed for this resident. Overall, the deficiency centers on the failure of nursing staff to promptly verify the resident’s full code status, initiate CPR immediately upon finding him pulseless and not breathing, and maintain life-sustaining efforts in accordance with facility policy, professional guidelines, and state law governing resuscitation and DNR orders. The sequence of events, as corroborated by multiple staff interviews and documentation, shows delays in response, premature assumption of death, miscommunication about code status, and an improper attempt to change the resident’s code status to DNR without the required legal process, all occurring before and during the emergency response that ended with the resident’s death.
Removal Plan
- Provide education to licensed nurses on the CPR policy, including confirming code status in the medical record, assessing when to initiate CPR, when CPR can be stopped, and pronouncing death.
- Educate licensed nurses on properly assessing prior to initiating CPR (check for pulse, observe chest rise, listen and feel for breathing, observe skin and body findings).
- Educate licensed nurses on the facility Cardiopulmonary Resuscitation (CPR) & Basic Life Support (BLS) policy, including that full code residents must receive BLS/CPR prior to EMS arrival unless obvious clinical signs of irreversible death are present, and defining those signs (rigor mortis, dependent lividity, decapitation, transection, decomposition).
- Educate licensed nurses that the licensed nurse on each shift is responsible for coordinating the rescue effort and directing other team members during the rescue effort until EMS has arrived.
- Educate licensed nurses that a resident may be declared dead by a Licensed Physician or Registered Nurse with physician authorization in accordance with state law per policy.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to maintain documentation that 14 of 41 licensed nurses had current CPR certification for Healthcare Providers. CPR cards were not available for several RNs and LPNs, and the NHA and DON confirmed the facility did not ensure these nurses maintained current CPR certification in accordance with accepted national standards.
An agency CNA found a full code resident unresponsive, but an agency RN did not check for a pulse or vital signs and did not start CPR before leaving to call EMS and look for help. Staff present were not CPR certified, and EMS arrived to find the resident pulseless and apneic with no CPR started by the facility. The resident later died at the hospital.
Facility staff failed to ensure that an LPN and a CNA maintained current CPR certification while working scheduled shifts. Interviews with the Administrator, DON, and HR Director confirmed that RNs, LPNs, and CNAs were expected to hold active CPR cards, and record review showed the LPN’s CPR had expired before renewal while the CNA could not produce a valid CPR card for the employee file. Staffing schedules showed both employees worked multiple shifts despite the lapse, and the job descriptions for both roles required current CPR certification.
A full-code resident with atrial fibrillation, liver cirrhosis, and osteomyelitis was found unresponsive after a family member alerted staff to breathing trouble. Staff entered the room without emergency equipment, and CPR was not started promptly; records and interviews showed delays in recognizing the emergency, calling Code Blue/911, and bringing in the AED, AMBU bag, and crash cart. The resident later expired, and the death certificate listed myocardial infarction as the cause of death.
LPNs and RNs did not maintain current CPR certification for Healthcare Providers with a required hands-on component. Facility policy required active CPR certification for licensed nurses, but review of certification cards showed that 16 of 33 licensed nurses had only online-only CPR training for non-healthcare providers. The HR Director, NHA, and DON confirmed the deficiency.
A resident with CHF was found unresponsive and CPR was performed even though the chart contained an active DNR order, an MDS indicating DNR, and a POLST choosing DNR and allowing natural death. LN stated she reviewed the physician order at the time and confirmed the resident was DNR, and the DON confirmed the resident's orders and POLST indicated DNR.
Missing Current CPR Certification for Licensed Nurses
Penalty
Summary
The facility failed to maintain documentation that its nursing personnel had current education and certification to provide basic life support, including CPR, prior to the arrival of emergency medical personnel and subject to physician orders and residents’ advance directives. A review of the facility’s CPR policy showed it was intended to ensure timely and appropriate initiation of CPR by licensed nursing staff in accordance with facility policy, resident rights, and federal and state regulations. During the survey, the facility provided a list of 41 currently employed licensed nurses and copies of CPR certification cards for review. CPR certification cards were not available for RN Employees E3, E4, E5, E6, and E7 and LPN Employees E8 through E16, totaling 14 of 41 licensed nurses. In an interview, the Nursing Home Administrator and the DON confirmed that the facility failed to ensure these nursing personnel maintained current CPR certification for Healthcare Providers through a CPR provider whose training included a hands-on session in a physical or virtual instructor-led setting in accordance with accepted national standards.
Failure to Start CPR for Full Code Resident
Penalty
Summary
The facility failed to assess a resident for a pulse or vital signs and failed to immediately start CPR for a resident who was a full code and was found unresponsive. Resident #60 had diagnoses including multiple fractured ribs on the left side, acute respiratory failure with hypoxia and hypercapnia, type 2 diabetes mellitus with diabetic peripheral angiopathy, CHF, PVD, osteoarthritis of the left knee, and atherosclerotic heart disease of the native coronary artery. The resident’s code status was documented as full code, and the care plan stated CPR should be started and EMS called if needed. According to the CCTV timeline and staff statements, an agency CNA found the resident unresponsive during rounds and summoned nursing staff. An agency RN arrived at the room, briefly entered, and then left without taking vital signs, checking for a pulse, or starting CPR. The RN then went to the nurses’ station and made calls while the resident remained without CPR. Other agency CNAs were present, but they were not CPR certified. EMS arrived several minutes later and found the resident unresponsive, pulseless, and apneic, with no evidence that facility staff had started CPR before EMS arrival. The 911 audio, CAD log, EMS report, police report, and witness statements all reflected that the resident was found unresponsive and that the facility did not initiate CPR. The police officer reported staff were standing in the room and did not know what to do, and EMS reported the facility staff did not start CPR and did not know the approximate down time. The hospital record stated the resident had been found unresponsive by nursing facility staff, no CPR had been performed by the facility for over ten minutes, and EMS initiated CPR and ACLS during transport. The resident was later pronounced dead at the hospital.
Failure to Maintain Current CPR Certification for Nursing Staff
Penalty
Summary
The facility failed to ensure that a nurse and a CNA maintained current CPR certification while working in the facility. Surveyor interviews and record review showed that facility leadership and HR stated that RNs, LPNs, and CNAs were required to have active CPR certification, and that CPR was needed because staff would respond during a code until EMS arrived. Despite this, the surveyor was unable to obtain a current CPR certification card for a CNA after multiple requests to the Administrator, Assistant Administrator, and DON, and the HR Director stated that the CNA had not produced a valid CPR certification for the employee file. Record review also showed that an LPN had worked multiple night shifts while her CPR certification had expired. The LPN confirmed receiving an HR email about the expiration and stated she renewed her CPR certification on the day of the interview. The expired CPR certificate showed the prior certification had lapsed before the renewal date. The HR Director stated she had sent an email about the upcoming expiration but did not follow up after returning from medical leave. Daily staffing schedules showed that the LPN and CNA worked multiple shifts during the review period despite not having active CPR certification. The facility’s job descriptions for both LPNs and CNAs stated that current CPR certification was required. The facility census report showed 149 residents in the facility at the time of the survey.
Delayed CPR Initiation for Full-Code Resident
Penalty
Summary
The facility failed to initiate CPR in a timely manner for a resident who was full code and found unresponsive. The resident had diagnoses including atrial fibrillation, liver cirrhosis, and osteomyelitis of the right ankle and foot, and the MDS documented moderately impaired cognition. The medical orders, MOLST, and care plan all documented full code/CPR status. Surveillance video showed that after a family member alerted staff that the resident was unresponsive, RN #11 and PCT #5 entered the room without emergency equipment. RN #12, the Assistant DON, later entered the room without equipment, and no medical equipment was observed being brought to the room for several minutes. The video also showed multiple staff entering and exiting the room over time, with the AED, AMBU bag, cardiac board, and crash cart not brought in until much later. The Code Blue/CPR worksheet documented CPR as initiated at 7:01 PM, while other records and staff statements reflected delays and inconsistent times for when the resident was found, when CPR began, and when EMS was called. Staff interviews described that the resident was breathing slowly at first, then became unresponsive, with inability to obtain a pulse or blood pressure. PCTs stated they notified RN #11 after the family member reported trouble breathing, and one PCT stated RN #12 said the resident had already passed away before CPR began. RN #14 stated they responded to an overhead Code Blue and saw RN #12 performing CPR, while the DON later stated the facility’s investigation found CPR was not initiated until RN #13 entered the room. The resident expired at 7:22 PM, and the death certificate listed myocardial infarction as the cause of death.
LPNs and RNs Lacked Acceptable CPR Certification
Penalty
Summary
Facility nursing personnel did not maintain current CPR certification for Healthcare Providers through a CPR provider whose training included a hands-on session either in a physical or virtual instructor-led setting in accordance with accepted national standards for 16 of 33 licensed nurses. The affected staff included LPNs E1 through E12 and RNs E13 through E16. The facility policy titled Cardiopulmonary Resuscitation CPR stated that licensed nurses, respiratory therapists, and van drivers must hold active CPR certification for healthcare providers, and that online-only courses were not acceptable. Review of the CPR certification cards for the 16 licensed nurses showed that their certification was from an online-only CPR class for non-healthcare providers and did not include a hands-on session. During an interview, the Human Resources Director confirmed that these employees did not have the appropriate CPR certification for licensed nurses. The Nursing Home Administrator and the DON also confirmed that the facility failed to ensure that facility nursing personnel maintained current CPR certification for Healthcare Providers through a CPR provider whose training included a hands-on session either in a physical or virtual instructor-led setting.
CPR Performed Despite Active DNR Order
Penalty
Summary
The facility failed to confirm the code status of Resident 96 during an emergency when LN 3 performed CPR after the resident was found unresponsive. Resident 96 had been readmitted with a diagnosis of congestive heart failure, and the record showed an active physician order for DNR, along with an MDS assessment and POLST indicating DNR and allowing natural death to occur. During interview, LN 3 stated CPR was performed after Resident 96 was found unresponsive and that she reviewed the physician order at that time and confirmed the resident's code status was DNR. The MDS Coordinator confirmed the POLST and MDS assessment indicated DNR, and the DON confirmed the OSR showed an active DNR order and stated the physician's order and POLST were expected to be carried out correctly; otherwise, the resident's wishes were not honored.
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