F0678

J

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

White Bear Lake, Minnesota Survey Completed on 02-02-2026

Penalty

Fine: $26,685

Summary

The deficiency involves the facility’s failure to immediately initiate CPR and activate EMS for a resident with a documented full code status who was found unresponsive. The resident had diagnoses including enterocolitis due to Clostridium difficile, a non-pressure ulcer of the left foot, and peripheral vascular disease, and required partial to moderate assistance with grooming and transfers. A physician order indicated the resident was full code, and the resident’s MDS showed a BIMS score of 15, indicating cognitive intactness.

According to the report, around midnight a nursing assistant observed that the resident’s chest was not rising, the resident did not respond to attempts at arousal, and appeared not to be breathing. The NA immediately notified an LPN, who went to the room and found the resident in bed with the head of the bed elevated and the head tilted to the right. The LPN was unable to locate a radial pulse, observed no chest rise, and noted the resident’s forehead felt cool. The LPN did not pull back the covers to further assess the resident, did not verify the code status, did not announce a code blue, and did not give instructions to the NA. Instead, the LPN called another nurse to come to the unit, stating that before anything could be done, a second nurse was needed, and then waited approximately five minutes for that nurse to arrive.

When the second LPN arrived, she found the first LPN and the NA standing outside the resident’s room. Upon entering, she assessed that the resident was not breathing, checked the code status, and determined the resident was full code. She noted the resident’s body was warm and that rigor mortis had not set in, and immediately initiated CPR, directing staff to call 911, announce a code blue, and obtain the AED and crash cart. The facility’s policy specified that for an unresponsive resident with a full code order, EMS should be activated immediately and CPR initiated unless there were obvious signs of clinical death such as rigor mortis, dependent lividity, decapitation, transection, or decomposition, or other specified exceptions. The failure of the first LPN to promptly assess for irreversible signs of death and to immediately initiate CPR and activate EMS for this full code resident resulted in an Immediate Jeopardy citation.

Removal Plan

• Completed an investigation and identified that a nurse failed to initiate CPR immediately on a full code resident found unresponsive.
• Conducted a root cause analysis and identified that CPR was not initiated per facility policy and that delegation of duties during the code situation did not occur.
• Placed the involved nurse on leave pending the investigation and terminated employment.
• Educated staff on the processes and procedures to follow when a resident is found unresponsive.
• Audited and verified all residents’ code statuses as correct.
• Reviewed facility policies.