F0678

J

Failure to Initiate Timely CPR and Improper Code Status Handling for a Full Code Resident

Traverse City, Michigan Survey Completed on 01-07-2026

Penalty

No penalty information released

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.