Failure to Provide Effective CPR per AHA Standards and Facility Policy
Penalty
Summary
The deficiency involves the facility’s failure to provide CPR in accordance with American Heart Association (AHA) standards and facility policy for a resident who became unresponsive. The resident, admitted with diagnoses including atherosclerotic heart disease, peripheral vascular disease, and depression, had a documented code status of full code. When the resident was reported by a CNA as acting differently and then found clammy and nonresponsive, the LPN assessed the resident, attempted sternal rubs without response, went to the nurse’s station to call 911, and upon returning found the resident not breathing and without vital signs. The LPN then initiated CPR while the resident remained on the bed, without using a back board or moving the resident to a hard surface, despite acknowledging that CPR is more effective on a hard surface. Emergency services arrived and took over CPR, and the resident later expired at the hospital. Surveyors determined that CPR was not administered according to AHA standards, which emphasize the need for a firm, hard surface to maximize compression depth, and not according to the facility’s Code Blue and Crash Cart policy requiring trained staff to respond to cardiopulmonary arrest. The investigation also found that the LPN who performed CPR had a lapse in CPR certification, with their prior certification expiring in 01/2024 and a new card not issued until a later date, leaving a period during which they were not CPR certified. Another LPN reported not knowing the location of the crash cart or crash cart key when asked to retrieve an ambu bag during the event, and stated that CPR should be performed on a hard surface such as the floor or a back board. The DON stated that CNAs were trained to call the nurse and retrieve the crash cart, that nurses should know where the back board is and use it for CPR, and that nursing staff should be certified in CPR and know AHA guidelines, with CPR certification required bi-annually.
Removal Plan
- Educate all nursing staff on code blue procedures, crash cart policy, and the location of emergency equipment, including the crash cart and back board
- Ensure all remaining nursing staff complete education and acknowledge understanding of the procedures
- Do not assign staff who have not completed education to resident care duties
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