F0725

D

Failure to Initiate CPR and Improper RN Pronouncement 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 necessary emergency services, including CPR and EMS activation, for a resident who was documented as Full Code, and the pronouncement of death by an RN without a physician order authorizing RN pronouncement. The resident had been discharged from the hospital with a documented Full Code status and was admitted to the facility with diagnoses including Type II diabetes, acute kidney injury, and atherosclerotic heart disease. On admission, the nursing assessment confirmed the resident was oriented and Full Code, and physician orders also reflected Full Code status. Vital signs obtained during the night showed a blood pressure of 168/70 with a temperature of 98°F, and later a blood pressure of 137/44 with a temperature of 95°F.

In the early morning, an LPN went to the resident’s room to obtain a blood glucose level and found the resident pulseless and without respirations. The LPN did not know the resident’s code status, did not confirm it because the computer was not on, and identified the EMR as the only place to 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 did not call a code blue, did not initiate CPR, and did not activate EMS, later acknowledging that he/she should have confirmed the code status, called a code blue, and started CPR. The second LPN, after being informed the resident had expired, assessed the resident, found no pulse, noted no stiffness of extremities or fingers, and also did not initiate CPR, later stating that CPR, a code call, and EMS activation should have occurred once the resident was found without pulse and respirations.

The RN responded approximately four to five minutes after being notified that the resident was not breathing, assessed the resident by auscultating lungs and heart, evaluating the eyes, and checking for blood pressure, and determined the resident had expired. The RN did not initiate CPR, stating the belief that rigor mortis had already set in, and contacted the Administrator to report the resident’s death. A subsequent progress note documented the resident as pulseless, without respirations, and pronounced expired, and later that the provider was notified and an order received to release remains to the funeral home. The facility’s Director of Nursing stated that for a Full Code resident found without pulse and respirations, staff should call for help, overhead page a code blue three times with room and location, and immediately initiate CPR, and confirmed that a physician’s order is required for RN pronouncement of death. The facility’s policies required CPR to be performed on appropriate residents by CPR-certified staff and specified that RN pronouncement of death is only permitted when the attending physician has documented an anticipated death and authorized RN pronouncement in writing, conditions that were not met in this case. The attending physician stated that CPR and EMS activation should have been initiated once the resident was found pulseless and apneic, and that EMS activation was required because there was no physician order authorizing RN pronouncement.