F0678

J

Failure to Initiate CPR and Maintain Accurate POLST/Code Status Information

Bellingham, Washington Survey Completed on 02-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure immediate initiation of CPR for two residents who were found unresponsive, not breathing, and without a pulse, despite having physician orders to attempt resuscitation or, in one case, an unknown code status that required CPR by policy. The facility’s CPR policy required licensed nurses to maintain current CPR certification and to initiate CPR for residents who requested it via advance directives or POLST, as well as for residents without a documented directive, while another staff member verified code status using a centrally located POLST binder. Surveyors found that the POLST binders on both floors were disorganized: some residents’ POLST forms were filed under the wrong room, one resident’s form was on the wrong floor, and several residents had duplicate POLSTs with conflicting CPR choices. Staff interviews showed confusion about where to find code status information, with at least one NAC believing it was in the electronic service plan rather than the POLST binder.

For Resident 1, who had diagnoses including endocarditis and sepsis, a signed POLST documented a choice for full resuscitation/CPR if they had no pulse and were not breathing. On the morning in question, the resident experienced breathing difficulty; a NAC reported the resident calling for help, appearing short of breath, and being coached through breathing exercises while on oxygen, then assisted back to bed and reported to a nurse. Later, a therapist found the resident unresponsive in bed, not waking or responding even to a sternal rub, and notified nursing staff. Multiple licensed nurses and a nurse practitioner entered the room, assessed the resident, and confirmed absence of pulse and respirations. Although someone in the room stated the resident was a full code, no one initiated CPR while staff discussed or attempted to verify code status. EMS records showed that 911 was called and EMS arrived at the bedside 14 minutes after the call, at which time EMS personnel, not facility staff, initiated CPR. The facility’s own investigation and staff interviews confirmed that no licensed staff started CPR on Resident 1 despite the full-code POLST.

For Resident 2, who had diagnoses including a bladder tumor, kidney disease, and vasovagal response, the facility’s incident report documented an unwitnessed fall and an unanticipated death at the same time. The report and associated statements lacked a clear timeline, did not specify who performed CPR, how long it was performed, or which staff were involved. EMS documentation indicated that EMS was notified early in the morning and arrived to find the resident unresponsive, with CPR having been initiated but then stopped, and it was unclear why CPR was not in progress upon EMS arrival. One LPN stated they helped another nurse move the resident back to bed and applied oxygen after finding a pulse, then went to the nurse’s station to look for the resident’s code status but could not locate it, and did not perform any CPR. Two NACs described being directed to start CPR: one placed a rescue board and counted respirations while the other performed 30–50 chest compressions, then stopped when nurses arrived and did not provide further direction. Neither NAC had current CPR certification on file, and one NAC stated they were the only person who provided compressions and stopped due to fatigue, with no nurse taking over. Another RN reported only assisting with locating code status and bringing the crash cart, without going to the resident’s room or assessing them. Facility leadership confirmed that CPR was required when code status was unknown, but staff did not consistently initiate or continue CPR in accordance with that expectation.

The surveyors determined that these failures—delayed or absent initiation of CPR for residents found pulseless and not breathing, disorganized and inaccurate POLST binders, staff confusion about where to find code status, and reliance on uncertified NACs to perform CPR without nurse oversight—constituted noncompliance with the requirement to provide basic life support, including CPR, prior to EMS arrival, subject to physician orders and advance directives. The deficiency was cited at F678 and determined to be Immediate Jeopardy, beginning when the facility failed to perform CPR immediately for a resident with a physician order to initiate CPR.

Removal Plan

• Educating staff in emergency response
• Reviewing the facility CPR policy with staff
• Reviewing all residents' POLST forms for accuracy
• Ensuring CPR training is completed
• Implementing a plan of correction to sustain ongoing compliance