CPR Discontinued Early for Full-Code Resident Prior to EMS Arrival
Penalty
Summary
Facility staff failed to ensure a full-code resident’s wishes regarding cardiopulmonary resuscitation (CPR) were honored when CPR was discontinued prior to EMS arrival. The resident had diagnoses including COPD with acute exacerbation, nontraumatic intracerebral hemorrhage, and malignant neoplasm of the kidney, and was documented as a full code on the face sheet, care plan, and physician orders. The care plan and facility CPR policy required that staff provide basic life support, including CPR, in accordance with the resident’s advance directives and continue CPR prior to EMS arrival if the resident did not show obvious signs of clinical death. On the morning of the incident, an LPN entered the resident’s room and observed the resident sitting on the side of the bed with a cup in hand, appearing as if preparing to get a drink. After tending to the roommate and returning, the LPN noted the resident was unresponsive, with fluid coming from the nose and mouth, and no palpable pulse. The LPN asked another staff member to verify the resident’s code status, was informed the resident was full code, and directed staff to call 911. The LPN initiated chest compressions, during which fluid continued to come from the resident’s mouth and nose. The LPN rolled the resident to the side to allow more fluid to drain, observed vomit on the bedding, and then rolled the resident back and continued compressions. The LPN reported the resident felt room temperature and that the chest felt soft and mushy during compressions. According to written statements and interviews, the LPN stopped CPR after determining the resident had aspirated and believing resuscitation was not possible, despite the resident’s full-code status and without EMS on scene. CNA and CMT staff present confirmed that CPR was started and then discontinued, and that the LPN declined to continue compressions or use suction, stating the resident had aspirated too much and that nothing more could be done. EMS personnel and the county coroner later arrived and found the resident with dependent back lividity and no CPR in progress; both stated that CPR should have been continued until EMS arrival. Multiple staff interviews, including CNAs, CMTs, LPNs, the DON, the Administrator, and the Medical Director, consistently described that facility practice and expectations were to initiate CPR for full-code residents and continue until EMS arrival or a physician pronouncement, indicating that in this case staff actions did not follow the resident’s documented wishes or the facility’s stated process.
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