Failure to Ensure Readily Accessible Code Status Resulted in No Emergency Response for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s advance directives/code status were readily accessible to staff during an emergency, resulting in no emergency response being initiated for a resident documented as Full Code. The resident was admitted from the hospital with diagnoses including Type II diabetes, acute kidney injury, and atherosclerotic heart disease, and the hospital discharge summary, nursing admission assessment, and physician’s orders all identified the resident as Full Code. When an LPN entered the resident’s room early in the morning to obtain a blood glucose level, the resident was found pulseless and without respirations. The LPN did not know the resident’s code status, could not access the EMR because the computer was not on, and believed the EMR was the only place to confirm code status. The LPN performed a sternal rub with no response, then left the room, asked another LPN to check on the resident, and paged an RN, but did not call a code blue or initiate CPR. When the RN arrived approximately four to five minutes after being notified, the RN assessed the resident, determined the resident was pulseless and not breathing, and pronounced the resident expired without initiating CPR, stating that they believed rigor mortis had already set in. The RN later acknowledged that CPR should have been initiated, that a code should have been called, and that EMS should have been activated, and confirmed that facility practice was to follow the hospital discharge documents, which indicated the resident was Full Code. Another LPN also stated that facility practice was to follow the hospital discharge summary for advance directives but was unaware that this resident was Full Code. Facility administration reported the facility was transitioning from paper charts to an EMR system and did not have a process to ensure advance directives for newly admitted residents were readily identifiable in the paper chart; such directives could be located within hospital documents or physician order sections, but administration could not say how long it would take to find them during an emergency. The facility’s own policy stated that adults have the right to control decisions related to their medical care and that advance directives are legally recognized written declarations specifying a person’s wishes for future care.
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