Failure to Honor Full Code Status and Initiate Timely CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s full code advance directive by not initiating CPR or other life-saving measures when the resident was found unresponsive. The resident had diagnoses including Parkinson’s disease with dyskinesia and encephalopathy and had a BIMS score of 0/15, indicating severe cognitive impairment. When an LPN went to care for the resident at approximately 4:45 PM, the resident was observed unresponsive, with eyes open and fixed, mouth open, and no vital signs detected. The LPN then approached another LPN and reported that the resident had passed, inquired about the code status, and was told the resident was a DNR. Based on this information, no immediate resuscitative efforts were initiated. A supervising RN was called to pronounce death and, upon arrival, found the resident cool to the touch and not breathing, and pronounced the resident deceased. Shortly afterward, another LPN discovered in the resident’s profile that the resident was actually a full code. The RN then initiated the facility’s code protocol and started CPR only after learning of the correct code status. Interviews revealed that the LPN who first found the resident unresponsive did not know the resident’s code status, did not know where code status was documented, and did not know the code status of any assigned residents. The facility’s policy stated that decisions regarding treatment and advance directives were to be documented in the medical record and communicated to staff responsible for the resident’s care. The Administrator confirmed that, due to the unexpected death, the facility’s response to provide CPR and other life-saving measures was delayed.
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