F0835

E

Failure to Implement Effective CPR System for a Full Code Resident

Shenandoah, Pennsylvania Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the failure of the Administrator and Director of Nursing (DON) to establish, implement, oversee, and enforce an effective cardiopulmonary resuscitation (CPR) system in accordance with federal requirements, facility policy, and American Heart Association (AHA) guidelines. The facility’s CPR policy required licensed or certified staff to initiate CPR when an individual was found unresponsive and not breathing normally, unless a valid Do Not Resuscitate (DNR) order existed or there were obvious irreversible signs of death. The policy also required that if code status was unclear, CPR must be initiated until a DNR or physician order not to resuscitate was confirmed, and that administrative systems ensure CPR readiness through staff education, competency, and adherence to AHA guidelines. AHA guidelines, as cited in the report, distinguish presumptive signs of death (such as unresponsiveness, absent respirations, absent pulse, fixed and dilated pupils, or cyanosis) from irreversible signs of death (such as livor mortis, rigor mortis, decomposition, or decapitation), with only the latter justifying not initiating CPR.

Resident CR1 was admitted with diagnoses including chronic obstructive pulmonary disease, hyperlipidemia, and hypertension, and had a physician order identifying the resident as Full Code. A face sheet from the referring facility, scanned into the electronic medical record, confirmed the resident’s preference to receive CPR. On a specified date at approximately 2:30 AM, staff found the resident unresponsive. Nursing documentation showed the resident was unresponsive to verbal and painful stimuli, had no detectable pulse, no obtainable blood pressure or oxygen saturation, and fixed and dilated pupils. There was no documented DNR or POLST in the record at that time, and documentation did not reflect the presence of irreversible signs of death. Despite this, licensed nursing staff did not initiate CPR prior to notifying the physician.

Facility-provided witness statements and staff interviews confirmed that licensed nursing staff deferred CPR while attempting to verify the resident’s code status, contrary to the facility policy requiring initiation of CPR when code status is unclear. Staff interviews also revealed a lack of understanding of irreversible signs of death and unawareness of any functional CPR team, despite policy language indicating such systems existed. The DON acknowledged that, at the time of the incident, the CPR policy had not been revised to clarify irreversible signs of death and that staff education had been conducted without ensuring comprehension or competency. As of the date noted in the report, the facility had not demonstrated that staff were competent to initiate CPR in accordance with resident wishes and AHA guidelines. The Administrator’s and DON’s job descriptions showed they were responsible for regulatory compliance, quality care, resident safety, and development and enforcement of nursing policies and procedures, but the failure to ensure timely initiation of CPR for this Full Code resident resulted in Immediate Jeopardy.