F0678

J

Failure to Initiate CPR for Full Code Resident

Pittsburgh, Pennsylvania Survey Completed on 01-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to initiate CPR for a resident who was a documented full code. The resident, identified as CR1, had diagnoses including chronic kidney disease, adult failure to thrive, and hypertension, and had a physician’s order indicating full code status current through the time of the incident. The resident’s advance directive form showed no advance directives, no living will, and no Power of Attorney, and there was no documentation that the resident had opted out of resuscitative efforts. The resident’s care plan, although current, did not include goals, plans, or interventions related to the resident’s full code status.

On the morning of the incident, an LPN (E3) documented that at approximately 7:45 a.m. the resident was found lying in bed on her right side, not responding to her name, with eyes open and skin pale and cool. The call bell was within reach, and the RN supervisor and physician were notified of a change in condition. In a written statement, the LPN reported that CPR was not started because the nurse believed the resident showed signs of irreversible death. There is no indication in the clinical record that the resident’s code status was unclear or that any conclusive signs of irreversible death, such as rigor mortis or other criteria described in the facility’s CPR policy and AHA guidelines, were present or documented at that time.

An RN (E4) later documented, in a late entry, that she was informed that the resident ceased to breathe at 7:56 a.m. and that the physician was notified and the resident pronounced deceased. In her statement, the RN reported that when she assessed the resident after being alerted by the LPN that there was no pulse, the resident’s eyes were open, the resident was pale and cool, and there was mottling of the extremities. The RN described these findings, along with the absence of pulse and respirations, as “obvious signs of death” and concluded that the resident had signs of irreversible death and that CPR would not have helped. The clinical record review confirmed that CPR was not administered despite the existing full code order, and staff interviews with other LPNs and RNs indicated that their understanding of procedure was to check code status and initiate CPR for full code residents found pulseless or without respirations. Surveyors determined that the facility failed to ensure consistent care by not initiating CPR for this unresponsive, pulseless full code resident, resulting in an immediate jeopardy situation.

Removal Plan

• Resident R1 no longer resides in facility.
• All professional nursing staff (LPN/RN) will be re-educated on the CPR procedure.
• Agency staff will be educated on the CPR procedure prior to the start of their next shift.
• All professional nursing staff (LPN/RN) will be re-educated on the definition of irreversible death and that it must be documented in the clinical record.
• Agency staff will be educated on the definition of irreversible death and documentation requirements prior to the start of their next shift.
• Whole-house audit will be conducted by the DON/designee to ensure that every resident has a completed POLST order form, the code status order in EHR, and the care plan updated accordingly.
• Policies related to CPR have been reviewed by NHA and DON and updated to include signs of irreversible death.
• Facility will review the incident in QAPI (Quality Assurance/Process Improvement) meeting.
• New admissions will be audited by DON/designee to ensure that the POLST is located in the resident chart and the DNR or Full Code status is in EHR.
• Findings of audits will be submitted through the facility QAPI program.
• All new hires will be educated on CPR procedures and signs of irreversible death.