F0678

J

Failure to Document and Act on Full Code Status Resulting in No CPR Initiation

Exton, Pennsylvania Survey Completed on 02-18-2026

Penalty

Fine: $53,550

Summary

The deficiency involves the facility’s failure to ensure that a resident’s code status was clearly documented and readily available in the clinical record, which delayed the decision to provide life-sustaining measures such as CPR. The American Heart Association (AHA) guidelines and the facility’s own CPR policy both state that CPR should be initiated for an unresponsive individual unless there is a valid DNR order or clear, irreversible signs of death. The facility’s policy further specifies that if a resident’s DNR status is unclear, CPR must be initiated and continued until a DNR or physician’s order not to administer CPR is confirmed. In this case, the resident’s hospital records and the attending physician’s encounter note documented the resident as “Full Code,” indicating the resident wished to receive all possible life-saving interventions.

The resident, identified as CL1, had been admitted from the hospital with acute respiratory failure with hypoxia and atrial fibrillation, and the hospital emergency room record and physician encounter note both documented a Full Code status. However, the facility’s physician orders for the resident did not contain any order for code status, and the code status was not displayed where staff expected to find it in the EMR or on the nurse’s sheet. On the night of the incident, the resident was last known to be responsive around 2:30 a.m. when an aide reported the resident rolled over and drank water. The nurse assigned to the resident observed the resident at midnight with a BIPAP mask on and again around 3:30 a.m. sleeping with a nasal cannula, noting the resident had a habit of removing the BIPAP mask.

Shortly before 5:00 a.m., an aide called the assigned nurse (Employee E4) to check on the resident. The nurse found the resident lying supine, appearing normally pale, and reported not feeling a pulse at the wrist or neck. Because the code status was not listed on the nurse’s sheet, the nurse and the nursing supervisor (Employee E3) spent approximately 10 minutes looking for the code status in the EMR, during which time an aide remained with the resident. The code status could not initially be found in the computer, and no CPR was started. The supervisor assessed the resident as gray, cool, with no breath sounds, no carotid or radial pulse, eyes closed, mouth open, and mottling on the legs, and later located documentation in the EMR under a miscellaneous section indicating the resident was Full Code. Despite this, CPR was not initiated. The DON confirmed that the resident’s code status should have been reflected in the EMR banner and on physician orders but was not, and also confirmed that staff did not initiate CPR, citing their belief that the resident showed irreversible signs of death. The surveyors concluded that the assessments described by staff did not meet the AHA or facility policy criteria for irreversible signs of death, and that the failure to document and locate the code status and to initiate CPR in accordance with the resident’s Full Code status constituted an Immediate Jeopardy situation.

Removal Plan

• Completed a full house audit of all residents to determine presence of code status and presence of a physician order.
• Reviewed CPR drills.
• Provided licensed staff education on CPR policy and procedures, including general guidelines with focus on assessment of unresponsive residents, when to initiate CPR, and identification of irreversible signs of death.
• Taught licensed staff that code status will be in PCC on the code status banner.
• Educated licensed staff on the Emergency Code documentation form, including the narrative of details during the code.
• Educated licensed staff on compliance with physician orders related to the provision of CPR when indicated.
• Updated licensed staff orientation to include CPR and procedures, Emergency Code Documentation, and compliance with physician order.
• Audited the order listing report and admission/readmission documentation for presence of code status and corresponding order in PCC.
• Audited effectiveness of licensed staff training via questionnaires and on-the-spot interviews.
• Presented and reviewed all ongoing compliance audits at the QAPI meeting.
• Completed a code drill to ensure licensed nurses were prepared to respond to situations that required CPR.
• Scheduled remaining staff to receive the education prior to the start of their next shift.