F0678

J

Failure to Assess Change in Condition, Call 911, and Document Code Status for Newly Admitted Resident

Kankakee, Illinois Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to promptly assess a resident when a CNA was unable to obtain vital signs and the failure to ensure the resident’s code status was documented and available in the medical record. Around 6:30 AM, a CNA informed an agency RN that she could not obtain a blood pressure or heart rate for the resident. The agency RN stated she continued passing morning medications to other residents and did not immediately assess the resident. Approximately an hour later, around 7:45 AM, the agency RN went to administer medications to the resident, found the resident unresponsive, and was unable to obtain vital signs or detect a heartbeat with a stethoscope.

After finding the resident unresponsive, the agency RN left the bedside to locate another RN working on a different hall and told her she thought the resident had expired and that the resident was DNR. The second RN went to the resident’s room, observed the resident to be pale with bluish lips but still warm, and confirmed there was no heartbeat or carotid pulse. She was then called away to attend to her own residents and left the unresponsive resident. Around 8:00 AM, the Social Service Director walked past the resident’s room, saw the resident slumped to the side in bed with staff present, and heard that staff could not obtain vital signs. He then asked a Respiratory Therapist to check the resident’s code status in the electronic record. The Respiratory Therapist found no code status orders in the chart, went to the room, assessed that the resident was not breathing and had no pulse, and initiated chest compressions. An LPN/Acting ADON then entered and took over compressions while the Respiratory Therapist applied an AED and began ventilations with a bag-valve mask.

During the code response, a Dietary Aide/CNA was called into the room to assist with CPR and completed two rounds of chest compressions. She reported that the Respiratory Therapist and Acting ADON were trying to determine who the resident’s nurse was and why 911 had not been called. The agency RN then entered and stated she had called a universal ambulance transport number and was unsure whether 911 should be called for an unresponsive patient. The Dietary Aide/CNA then called 911 from her personal phone; EMS records show 911 was called at 8:33 AM, with paramedics arriving shortly thereafter and taking over resuscitative efforts until the resident was pronounced deceased. The Assistant EMS Coordinator confirmed that only one 911 call was received for this event, from the Dietary Aide/CNA.

The resident had been admitted to the facility approximately 16 hours before the code event with a primary diagnosis of acute respiratory failure with hypoxia. The facility face sheet and physician order sheet contained no advance directive or code status, and there was no documented nursing assessment or vital signs for the resident after admission. The agency RN reported she was the admission nurse and that another LPN had taken the hospital report, which included the resident’s code status, but the agency RN did not remember what that status was and acknowledged it was the admission nurse’s responsibility to enter code status into the electronic record. The Admissions Director later stated that the hospital chart showed the resident was a partial code, with orders for no mechanical ventilation with intubation, selective cardio resuscitation, no chest compressions, and no defibrillation/cardio­version, but this was not discovered until after the resident’s death. The Administrator and DON confirmed that the resident’s code status should be obtained and entered into the system immediately upon admission so staff know how to proceed in an emergency, and that if no code status is present, staff are expected to initiate CPR immediately when a resident is found unresponsive.

Removal Plan

• Completed an audit of resident code status to ensure all current residents had a code status.
• Provided education to all nursing staff on code status and emergency response expectations.
• Ceased any practice of delaying CPR due to verbal assumptions of DNR status.
• Implemented a directive that all residents will be treated as full code unless a valid physician DNR order is present and accessible in the medical record.
• Completed a 100% audit of all current resident charts to verify presence of physician code status orders.
• Completed an audit to ensure DNR status was accurately reflected on nursing shift-to-shift reports and matched the DNR status in the chart.
• Placed an emergency code status roster at all nurse's stations for rapid access.
• Updated the change in condition policy to require nursing staff to immediately assess when vital signs cannot be obtained and not delay escalation.
• Nursing leadership to educate all staff (including agency) on the Do Not Resuscitate Order Policy, CPR Policy, and Change in Resident Condition Policy, and educate remaining staff prior to their next worked shift.
• Reeducated nursing staff on rooming responsibility for new residents including clinical assessment completion within 2 hours of arrival and completion of a move-in note, with daily auditing by the DON.
• Implemented an admissions checklist including DNR status to validate patient wishes prior to arrival.
• Director of Sales and Marketing to audit daily.
• Implemented an immediate requirement for licensed nurse assessment without delay upon inability to obtain vital signs or change in condition.
• Reeducated staff that CPR must be initiated unless a physician DNR order is confirmed.
• Verified all current agency staff have completed the orientation checklist prior to taking an independent patient assignment.
• Planned a QAPI action plan including audits of admission code status completion upon admission, admission checklist with code status known prior to admission, nursing assessment completion within 2 hours of admission by admitting nurse, nursing completion of move-in note upon admission, agency checklist completion prior to taking a full assignment, and weekly mock CPR code completion on each shift.