F0678

J

Failure to Initiate CPR and Activate EMS for a Full Code Resident

Bristol, Connecticut Survey Completed on 02-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide basic life support, including CPR and EMS activation, to a resident who was documented as Full Code. The resident had been 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. Vital signs obtained after admission showed elevated blood pressure and a decreasing temporal temperature. Later, a progress note by an RN documented that the resident was found pulseless and without respirations and was pronounced expired, with subsequent notification of the resident representative and provider.

When an LPN went to the resident’s room to obtain a blood glucose level, the LPN found the resident pulseless and without respirations. The LPN stated they did not know the resident’s code status and did not confirm it because their computer was not on, and indicated that the EMR was the only place they could find 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 the RN to report that the resident was pulseless and not breathing. The LPN acknowledged that they should have confirmed the code status, overhead paged a code blue, and initiated CPR.

The RN reported arriving at the room approximately four to five minutes after being notified that the resident was not breathing, assessed the resident, and did not initiate CPR because they believed rigor mortis had already set in, despite acknowledging that CPR should have been started. Another LPN who checked the resident confirmed the absence of a pulse, noted the resident’s hands were folded with fingers intertwined, and reported that the resident’s arm and fingers were not stiff when moved to palpate a radial pulse, yet did not initiate CPR and later stated CPR, a code call, and EMS activation should have occurred. The physician interviewed stated that CPR and EMS activation should have been initiated once the resident was found pulseless and without respirations, and that EMS activation was required because there was no physician’s order authorizing an RN to pronounce death. The DNS stated that for a Full Code resident found without pulse and respirations, staff should call for help, announce a code blue over the intercom with room and location, and immediately start CPR, and that residents are considered Full Code unless otherwise decided after admission.

Removal Plan

• Audited all resident charts to confirm code status was active in the electronic medical record (EMR).
• Educated all nursing staff on Response to Unresponsive Residents and Code Status, CPR, and conducted a Mock Code followed by a code debrief on all shifts.
• Performed a Code Procedure Checklist (competency evaluation) for all licensed staff.
• Conducted code blue mock drills.
• Scheduled the corrective action plan for QAPI review.