F0678

D

Failure to Follow Full Code Status, Timely Activate EMS, and Use AED During Cardiac Arrest

Lapeer, Michigan Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to correctly identify a resident’s code status, promptly notify EMS, and use an available AED during a cardiac arrest event. The resident had multiple serious diagnoses, including metabolic encephalopathy, COPD, heart disease, PVD, epilepsy, dementia, kidney failure, anemia, and aphasia, and was severely cognitively impaired per the MDS, requiring assistance with all care. Documentation in the EMR, including a Code Status/Do Not Resuscitate Directive form, physician orders, and the care plan, all indicated that the resident was a Full Code, with instructions that the resident wished to receive CPR and other life-sustaining treatments. Despite this, when the resident was found unresponsive and not breathing, staff became confused about whether the resident was a Full Code or DNR.

When the Code Blue was called, Nurse C began CPR based on her report sheet, which indicated Full Code, and the crash cart was brought to the room. Nurse D went to the nurses’ station to verify the code status and misinterpreted the documentation that stated “Full code by default,” leading to confusion among staff. During this time, a nurse aide overheard the misinterpretation and communicated to EMS that the resident was a DNR, resulting in cancellation of EMS response. Multiple staff interviews, including those of Nurse D, Nurse Aide E, the HR Manager, and a confidential witness, described the scene as hectic and chaotic, with uncertainty among staff about the resident’s code status and repeated calls to 911 in which staff alternately reported that EMS was needed, then not needed, and that the resident was a DNR before later stating he was a Full Code.

EMS records and interviews confirmed that the facility first called 911 reporting an unresponsive resident, then cancelled the request, then called again to say EMS was not needed because the resident was DNR, and finally called back later stating the resident was a Full Code and deceased. When EMS arrived, they found staff performing CPR with a BVM in use, but the CPR backboard was placed under the lumbar area instead of the thoracic area, and the crash cart drawers had not been opened. The AED present on the crash cart had not been opened or applied to the resident, despite being available. Review of staff CPR credentials showed that not all nurses present had current AHA BLS for Healthcare Provider certification, and some had only standard or non–healthcare-provider CPR training without clear AED training. The facility also lacked a specific CPR policy, and the DON stated that nurses were expected to follow their training, which did not ensure consistent BLS for healthcare providers, including early AED use, during this emergent event.

The facility’s own Advance Directives Policy stated that Full Code status meant the resident would receive full resuscitation and life-sustaining treatment, including CPR, and that Full Code status was indicated on the Code Status/Do Not Resuscitate Directive form. Despite this, staff did not consistently follow the documented Full Code status during the event. The combination of misinterpretation of code status documentation, delayed and inconsistent communication with EMS, failure to use the AED, and improper CPR technique as observed by EMS contributed to the deficiency related to providing basic life support, including CPR, prior to the arrival of emergency medical personnel, in accordance with physician orders and the resident’s advance directives.