Failure to Initiate and Maintain CPR for Full-Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide continuous basic life support/CPR to a resident with a documented full code status who was found unresponsive in the bathroom. Facility policy required that any resident suffering cardiac or respiratory arrest receive CPR unless a valid DNR order was in place, and that basic life support be initiated and maintained until ambulance arrival. AHA BLS guidance similarly required immediate CPR when no breathing and no pulse are present, continuing until advanced life support personnel take over. The resident’s care plan and medical record showed he had elected full code status, had moderate cognitive impairment, used a wheelchair, and required assistance with transfers and ambulation. He had been treated for cirrhosis and hepatic encephalopathy and had a recent PRN order for Zofran for nausea, which was administered the evening before the event without documented effectiveness. On the morning of the incident, the resident’s roommate activated the call light after the resident had been in the bathroom for an extended period without sound. A CNA entered the room around 6:07 AM, found the resident on his knees slumped over the toilet and unresponsive, did not touch him, and immediately went to get the nurse. Video footage showed the LPN and two CNAs entering the room briefly and exiting after approximately 11 seconds, which the Regional Director later acknowledged was not enough time for a proper assessment. The LPN then left the room area and was at the nurses’ station when she first called 911, reporting that the resident was not breathing and that CNAs were performing CPR, although both CNAs later stated they did not perform CPR and did not see CPR performed by the nurse or EMS. The 911 operator instructed the LPN to go to the resident’s room and to call back from a cell phone so that the resident’s status could be directly assessed. During the second 911 call, the LPN reported that the resident was “gone,” that CPR had been stopped once he was pulled off the toilet, and confirmed that CPR was not being done. She described the resident as cold to touch, blue in the face, bleeding from the head, and without a pulse. Facility video showed that the crash cart did not arrive outside the resident’s room until about 6:20 AM, and there was no evidence that the AED on the crash cart was applied. EMS and fire personnel arrived within minutes and documented that the resident was dead without resuscitation efforts, with significant lividity and jaw rigor mortis, and pronounced him deceased at 6:30 AM. Interviews with the nurse practitioner, DON, and staff confirmed that for a full-code resident found without vital signs, CPR should be initiated and not discontinued prior to EMS arrival, and that in this case CPR was not initiated or continuously performed despite the resident’s full code status and absence of a DNR order. The surveyors concluded that the facility failed to provide continuous CPR as required, resulting in an Immediate Jeopardy citation at F-678.
Removal Plan
- Administrator and DON educated on BLS Standards, CPR Policy, and Facility Expectations during a Code Blue Response by the Regional Nurse
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