F0658

G

Failure to Initiate CPR for Full Code Resident

Shenandoah, Pennsylvania Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to initiate cardiopulmonary resuscitation (CPR) for a resident who had documented Full Code status. State professional nursing standards and the facility’s CPR policy require licensed or certified staff to initiate CPR when an individual is found unresponsive and not breathing normally, unless there is a valid Do Not Resuscitate (DNR) order or clear signs of irreversible death. The Pennsylvania nursing regulations cited in the report specify that RNs are responsible for nursing care actions that promote, maintain, and restore well-being, and may perform resuscitation when respiration or pulse cease unexpectedly, provided the employer authorizes it by policy and the nurse is competent. The facility’s policy on Emergency Procedure–Cardiopulmonary Resuscitation and Basic Life Support directs staff to initiate CPR in such circumstances in the absence of a DNR or obvious post-mortem changes.

The resident, identified as CR1, was admitted with diagnoses including COPD, hyperlipidemia, and hypertension, and was documented as having baseline confusion, requiring oxygen, and experiencing dyspnea. A face sheet from the referring facility, scanned into the electronic medical record one day prior to admission, indicated the resident’s code status as Full Code. A nursing progress note at the time of admission documented that attempts to complete admission documentation were unsuccessful because staff were unable to reach family to confirm code status, but there is no indication that this negated or superseded the Full Code designation on the transferred face sheet. Later that night, at approximately 2:30 AM, two nurse aides entered the resident’s room and found the resident unresponsive.

A nursing progress note at 2:30 AM by an RN documented that the resident was unresponsive to verbal commands and sternal rub, had no apical pulse, and that staff were unable to obtain blood pressure or oxygen saturation. One respiration was observed, the pupils were fixed and dilated, and the skin was warm and dry. A subsequent note at 3:55 AM by the RN supervisor documented the resident as unresponsive, pale, without measurable blood pressure, respirations, or detectable apical or carotid pulse. No DNR order or POLST was found in the record at that time, and there was no documentation of rigor mortis, dependent lividity, or other signs of irreversible death. One nurse aide reported not being CPR/AED certified and therefore did not initiate CPR, and stated that neither the RN nor the RN supervisor initiated CPR at any time. Personnel records confirmed that both the RN and RN supervisor held current CPR certification. Based on the record review, staff statements, and training documentation, surveyors determined that the RN and RN supervisor failed to initiate CPR for a Full Code resident who was found unresponsive and pulseless, resulting in actual harm because life-sustaining interventions consistent with the resident’s documented treatment preferences and accepted nursing standards were not provided.