F0678

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Failure to Initiate CPR for Full Code Resident and Inadequate Staff Adherence to CPR Policy

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) in accordance with a resident’s advance directives, physician orders, facility policy, and American Heart Association (AHA) guidelines. The facility’s CPR policy required that when an individual is found unresponsive and not breathing normally, licensed or certified staff must initiate CPR unless there is a known Do Not Resuscitate (DNR) order specifically prohibiting CPR or obvious signs of irreversible death, such as rigor mortis. The policy also stated that if a resident’s DNR status is unclear, CPR must be started and continued until a DNR or physician order to withhold CPR is confirmed. AHA guidelines referenced in the policy distinguish presumptive signs of death (such as unresponsiveness, absence of respirations and pulse, fixed and dilated pupils, cool skin, and cyanosis) from conclusive, irreversible signs of death (such as livor mortis, decomposition, decapitation, and rigor mortis).

Resident CR1 was admitted with diagnoses including chronic obstructive pulmonary disease, hyperlipidemia, and hypertension. A face sheet from the referring facility, scanned into the electronic medical record prior to admission, documented the resident’s code status as Full Code, indicating a preference to receive CPR in the event of cardiac or respiratory arrest. A nursing note at admission documented baseline confusion, oxygen therapy, and dyspnea, and also noted that attempts to complete admission documentation were unsuccessful because family could not be reached to confirm code status and obtain the resident’s CPAP machine. Despite the presence of the referring facility’s face sheet indicating Full Code status, the resident’s code status was not documented in the facility’s system at the time of the incident.

At approximately 2:30 AM, two nurse aides entered the resident’s room and found the resident unresponsive. One aide, who was not CPR/AED certified, did not initiate CPR and instead summoned a registered nurse (RN). The RN’s progress note documented that the resident was unresponsive to verbal commands and sternal rub, had no apical pulse, no obtainable blood pressure or oxygen saturation, one observed respiration, fixed and dilated pupils, and warm, dry skin. The RN did not initiate CPR and directed one aide to check the resident’s code status in the electronic record; the aide reported that no code status was documented. The RN then directed staff to call the RN supervisor. When the RN supervisor arrived, she documented that the resident was unresponsive, pale, with no blood pressure, no pulse oximetry reading, no apical or carotid pulse, no respirations, and no response to sternal rub, and that no DNR or POLST was located in the chart or electronic system. The physician was contacted regarding the resident’s death, and no CPR was initiated at any point, despite the absence of documented irreversible signs of death and the lack of any DNR order.

Witness statements provided by staff were consistent in describing the resident as unresponsive with absent vital signs and fixed, dilated pupils, and confirmed that neither the RN nor the RN supervisor initiated CPR. The facility was unable to provide justification for the failure of these licensed nurses to initiate CPR for a resident who did not exhibit documented irreversible signs of death and who was later identified in the closed record as Full Code. Additionally, interviews with multiple LPNs revealed they were unaware of the facility’s policy provisions regarding a designated CPR team and could not identify signs of irreversible death, indicating that staff had not effectively received or understood the CPR policy requirements. Review of other residents’ records showed that 47 additional residents had current physician orders to receive CPR, and the facility’s failures placed these residents, along with Resident CR1, in Immediate Jeopardy to their health and safety.

Removal Plan

• Employee 1 (RN) and Employee 4 (Agency RN Supervisor) were educated on the Emergency Procedure - Cardiopulmonary Resuscitation policy and the need to initiate CPR immediately in accordance with resident wishes and were immediately suspended.
• The facility educated licensed clinical staff on revisions of the CPR policy, including how to respond when someone is unresponsive and when not to initiate CPR (obvious signs of irreversible death) and that if no code status is documented the resident is treated as full code.
• The facility used the payroll system to send the updated CPR policy to staff for electronic review and acknowledgment.
• Nursing education on the updated CPR policy and irreversible signs of death will continue to be completed with licensed staff prior to their next shift starting, beginning with 11pm to 7am shift staff.
• Licensed staff education will be completed regarding the need to initiate CPR immediately in accordance with resident wishes and where to locate code status for each resident in Point Click Care (PCC), on the resident face sheet, and in the orders.
• The facility will ensure each licensed staff member is educated on irreversible signs of death so staff know when it is acceptable not to initiate CPR.
• Education will continue prior to each licensed staff member's next shift.
• Residents’ code statuses were confirmed as reflected in PCC on the resident’s face sheet and in the resident’s orders.
• The Director of Nursing (DON) or designee will audit EMR code status to validate consistency of records for staff reference.
• The DON or designee will audit CPR certification for licensed facility staff.
• The facility conducted a CPR class for employees who were unable to produce up-to-date CPR certification information.