Failure to Initiate Immediate CPR and Provide Adequate BLS and Oxygen Equipment for a Full-Code Resident
Summary
The deficiency involves the facility’s failure to provide proper and effective Basic Life Support (BLS), including immediate CPR, to a resident who was documented as full code. The resident had multiple cardiac-related diagnoses, including diabetes mellitus, congestive heart failure, dementia, atrial fibrillation, and atherosclerotic heart disease, and a POLST indicating that resuscitation/CPR should be attempted with full treatment status. The resident’s care plan identified potential for cardiac distress and directed staff to monitor for symptoms such as dyspnea, shortness of breath, tachycardia, edema, and to promptly contact the physician if symptoms occurred. On the day of the event, the resident had been stable earlier and ate 100% of dinner, but later became weak, had shallow breathing, stopped talking, and became unresponsive. When the change in condition occurred, CNAs observed the resident become unresponsive with eyes rolling back and immediately summoned nursing staff. RN 1 responded and found the resident sitting up at approximately a 70–90 degree angle, unresponsive, with shallow breathing and not verbally responsive, but making noises. RN 1 proceeded to obtain vital signs and reported normal blood pressure, heart rate, respiratory rate, and oxygen saturation initially at 98%, later dropping to 96% and then 89%. Instead of immediately initiating CPR or placing the resident supine on a firm, flat surface with a head-tilt, chin-lift to open the airway, RN 1 left the room to verify code status and retrieve the crash cart. RN 1 stated he did not initiate CPR because the resident made a noise in response to painful stimulation of the ear and he believed this indicated responsiveness. Staff did not initiate chest compressions while the resident remained unresponsive with shallow breathing, and no reassessment of oxygen saturation was documented after oxygen via simple mask was applied. Other licensed staff also failed to initiate BLS measures. LVN 1 reported that when called to the room, the resident was on oxygen via nasal cannula, breathing abnormally with two to three long breaths, and he recognized that 911 needed to be called, but he did not start CPR. LVN 2 stated that the resident was unresponsive and breathing slowly and acknowledged not being aware that ventilation could be provided when a resident is unresponsive and breathing slowly; vital signs she attempted to obtain were not documented. CNA 1 reported that no CPR was initiated by facility staff before EMS arrival. According to the EMS report and the responding Paramedic Captain, paramedics arrived to find the resident supine in bed, unresponsive, pulseless, apneic, and in asystole, with no CPR in progress and no measurable blood pressure, pulse, respirations, or oxygen saturation. The deficiency also included failure to ensure that emergency equipment and oxygen delivery systems were adequate and properly set up for resuscitation. The crash cart contained an oxygen regulator with a maximum output of only 8 L/min, which was insufficient to keep the BVM reservoir bag fully inflated and deliver 100% oxygen as required during resuscitation. The Paramedic Captain reported that the oxygen regulator connected to the resident’s oxygen tank was limited to 8 L/min, and another regulator found in the crash cart was also limited to 8 L/min, necessitating use of EMS’s own regulator to achieve 15 L/min, which delayed delivery of 100% oxygen. The Paramedic Captain also requested a backboard and was informed by RN 1 that the facility did not have one. Additionally, during surveyor observation and interview, RN 1 was unable to determine that the crash cart oxygen tank was empty and could not demonstrate proper connection of the suction tubing to the suction machine, stating he did not know how to determine whether the oxygen tank was empty or how to connect the suction machine. These failures occurred despite facility policies requiring immediate initiation of CPR for unresponsive residents without a DNR and the use of appropriate oxygen administration and emergency procedures. As a result of these findings, surveyors determined that the facility did not initiate immediate CPR for a full-code resident found unresponsive and did not perform continuous, uninterrupted CPR until EMS assumed care. The facility also failed to position the resident flat on a firm surface with airway opened, and failed to ensure availability and proper use of equipment capable of delivering 15 L/min oxygen for BVM use during resuscitation. EMS documentation indicated that no CPR was being performed upon their arrival, and the resident was found in cardiac arrest. The California Department of Public Health determined that the noncompliance constituted Immediate Jeopardy related to failure to ensure CPR was immediately performed on the resident.
Removal Plan
- RN 1 resigned from the facility.
- Staff involved (LVN 1, LVN 2) were removed by the DON from direct patient care until competency was validated.
- Immediate re-education was reinforced by the DON for direct care staff on immediate initiation of CPR, proper positioning on a firm/flat surface, continuous/uninterrupted CPR, crash cart utilization (including oxygen regulators capable of 15 L/min and backboards), and use of oxygen tanks (including how to determine if full or empty).
- Crash cart was checked by the DON and oxygen regulators were replaced to ensure 15 L/min capability; BVM bag and oxygen delivery systems were verified functional; oxygen tanks were ensured full.
- DON and DSD reviewed current certifications of all direct care staff and ensured only staff with validated CPR certification are assigned to residents' care.
- MRD identified residents designated as full code and ensured staff are aware where to find code status in paper medical records and the health record system.
- DON initiated in-service to licensed nurses (RNs/LVNs) and CNAs on the facility CPR emergency procedure policy with emphasis on calling code blue, locating code status, placing resident on firm/flat surface using backboard, head-tilt/chin-lift with oxygen via simple mask, using an oxygen regulator capable of 15 L/min for BVM, and performing continuous/uninterrupted CPR until EMS assumes care.
- Code Blue drills were initiated and will continue for skills check validation via return demonstration of licensed nurses and CNAs.
- A crash cart checklist was developed and implemented; crash cart and oxygen equipment checklist will be checked every shift by the lead licensed staff.
- Room changes will include updating residents' medical records to reflect new room assignment in both the electronic health record and physical medical record.
- A certified CPR instructor provided mandatory re-education and training for all licensed nurses and CNAs with return demonstration conducted.
- DSD/designee will validate that newly hired licensed nurses and CNAs have current valid CPR certification prior to scheduling for direct resident care; no direct care staff will work directly with residents without valid CPR certification.
- DON conducted a 1:1 in-service with LVN 1 and LVN 2 regarding medical emergency response (immediate CPR, proper positioning, continuous/uninterrupted CPR, crash cart utilization including 15 L/min regulators and backboards, and oxygen tank use/verification).
- DSD updated CPR certification status for all current direct care staff and will update monthly; DSD will audit and communicate with staff if CPR certification expires.
- DON/designee will provide a summary of findings for the monthly Quality Assurance Committee (QAC).
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with intact cognition, multiple medical diagnoses, and documented full code status was found unresponsive, pulseless, and nonbreathing while receiving care. An RN believed Hospice enrollment changed the code status to DNR and did not start CPR or call a code blue, despite the resident’s full code order being documented in the chart.
A resident with respiratory failure and COPD, whose advance directives and orders indicated Full Code, was found unresponsive by an RN. The RN checked for a pulse, confirmed the resident was gone, but did not start CPR or call EMS; another nurse also assessed the resident, and the resident was pronounced dead shortly after. Family members and the DON stated CPR was not initiated despite the resident’s Full Code status.
A resident with a documented DNRCCA order had CPR started during a respiratory emergency before the code status was verified, despite staff records showing the resident was DNRCCA and cognitively impaired. Staff reports described confusion during the event, with CPR initiated while family members were present and code status confirmation occurring after compressions had already begun. In a separate record review, another resident’s chart showed DNRCCA in the EMR and care plan, but the hard chart lacked signed code status documentation.
Ambu Bag Not Readily Available During Code Blue: A Full Code resident was found unresponsive and not breathing, and staff began CPR during a Code Blue, but an ambu bag was not readily available at the start of the event. Staff used a non-rebreather mask while looking for the ambu bag, and interviews confirmed the device was not in use when the code began. The DON stated an ambu bag is part of the expected emergency equipment and that a non-rebreather mask does not replace it.
A resident with full code status became unresponsive and staff began chest compressions, but an LPN did not immediately call 911 and CPR was performed without ventilations or rescue breathing. EMS arrived to find staff doing compressions only and documented that the resident had been without ventilations for more than 12 minutes before EMS initiated BVM ventilations and continued resuscitation efforts.
RN 2 did not maintain CPR/BLS certification from a provider that included the required hands-on skills component. File review showed the certification came from an online provider, and RN 2 stated the course was entirely online with reading, videos, and questions only, with no CPR skills demonstration. The DSD confirmed the certification needed hands-on validation under the facility CPR policy.
Failure to Provide CPR for Full Code Resident
Penalty
Summary
Facility staff failed to provide basic life support, including CPR, for a resident who was found pulseless and nonbreathing. The resident had diagnoses including peritoneal abscess, type 2 diabetes, and severe protein-calorie malnutrition, and a quarterly MDS assessment indicated a BIMS score of 13 out of 15, showing intact cognition. The resident was their own decision maker and had a documented full code status signed and dated in the medical record. The resident was enrolled in Hospice services, and on the night of the incident, CNA-G and CNA-H were providing a bed bath while RN-E entered the room to complete a skin check and change a dressing on the resident’s buttocks. After the dressing change, the resident began having loose stools. RN-E left to get additional wound supplies while the CNAs continued care, and CNA-H thought the resident had passed away and left to notify RN-E. RN-E returned, found the resident unresponsive without observable respirations or signs of life, and believed the code status had changed to DNR when Hospice services began. RN-E did not initiate CPR or call a code blue, and instead asked LPN-F to inform Hospice of the resident’s passing. The investigation found that the resident’s code status was accurately documented in the medical record, physician orders, and care plan, and that RN-E was aware the resident was full code but failed to follow the resident’s documented wishes and the facility’s emergency response procedures.
Failure to Initiate CPR and Call EMS for Full Code Resident
Penalty
Summary
The facility failed to initiate CPR and call EMS for a resident who was found unresponsive and had Full Code status. The resident had been admitted from an acute care hospital and had diagnoses including acute and chronic respiratory failure with hypoxia and hypercapnia, as well as COPD. Advance directives, the order summary, and the MAR/TAR all identified the resident as Full Code, and a progress note documented that the resident wanted to remain Full Code. According to the record and staff interviews, the resident was last seen at about 4:45 AM when a breathing treatment was started. At about 5:50 AM, an RN entered the room to tell the resident the shift was ending, found no response, touched the resident, and checked for a radial pulse, which was absent. The RN then went to the hallway and alerted the incoming nurse that the resident was gone. The RN later checked the chart and confirmed Full Code status, but CPR was not started and EMS was not called. Another nurse was present and also assessed the resident, with absent apical pulse confirmed, and the resident was pronounced dead at 6:00 AM. Family members stated they were told the RN panicked and did not start CPR or call EMS. The DON confirmed that the resident was Full Code and that the RN who found the resident unresponsive did not initiate CPR or check code status right away. The facility policy stated that when a resident is found without heartbeat and respirations, the nurse on duty identifies code status and, if the resident is Full Code, CPR is started and 911 is activated.
Advance directives not honored during CPR event and code status documentation incomplete
Penalty
Summary
The facility failed to honor advance directives for a resident with a documented DNRCCA order when CPR was initiated during a respiratory emergency. Resident #91 was admitted with acute respiratory failure with hypoxia, pulmonary embolism, and tracheostomy status, and the record showed the resident was cognitively impaired, totally dependent for ADLs, and had a physician order and care plan identifying DNRCCA status. During the event, staff were alerted that the resident was having trouble breathing, and the respiratory therapist entered the room, found the resident not breathing, and began CPR before the code status was verified. According to the facility investigation and staff statements, multiple staff members responded to the room, the crash cart was brought in, and CPR continued while EMS was called. One witness stated the family was asked if they wanted life support and said yes, while another witness stated the resident’s spouse and son were present and that the spouse was removed from the room. The regional nurse confirmed CPR was initiated when it should not have been because the resident had a DNRCCA order. The DON stated staff believed someone was sent to verify the code status while the code continued, and the respiratory therapist stated she did not have time to look in the chart before starting compressions. The facility also failed to ensure advance directive documentation was accurate in the medical record for another resident. Resident #28 had physician orders and a care plan indicating DNRCCA, but the record did not contain signed documentation verifying that status in the hard chart. A review of the electronic chart showed DNRCCA, while the regional nurse stated there was no signed code status paper in the medical record and reported that the resident had said he wanted to be a full code. The facility policy required advance directives to be maintained in the medical record and readily retrievable, and to be followed.
Ambu Bag Not Readily Available During Code Blue
Penalty
Summary
The facility failed to ensure the immediate availability of essential emergency resuscitation equipment for a resident who was designated Full Code during a Code Blue event. When the resident was found unresponsive and not breathing, staff initiated CPR, but an ambu bag was not readily available at the start of the emergency. Staff instead used a non-rebreather mask, and one nurse asked for an ambu bag to be brought from another floor. The resident’s code was documented as having been initiated immediately, with CPR continuing until EMS arrived and took over. Interviews confirmed that staff observed the ambu bag was not in use and was not readily available when the code began. A nurse stated that chest compressions were being performed when he arrived, but there was no ambu bag in use. Another nurse said staff were looking for the ambu bag and that it was not readily available at the start of the code, though one was brought in before EMS arrival. The DON stated that staff were expected to respond immediately with all necessary equipment, including an ambu bag, oxygen, and an IV starter kit, and acknowledged that a non-rebreather mask does not replace an ambu bag. The crash cart stock list identified one ambu bag on top of the cart, and the facility’s CPR policy stated that emergency basic life support should be provided immediately, including CPR, in accordance with physician orders and advance directives.
Failure to Provide Ventilations During Code Response
Penalty
Summary
The facility failed to provide basic life support to a resident with full code status when the resident became unresponsive and was found without vital signs. The resident had Huntington's disease, dysphagia, anxiety, gastrostomy status, severe cognitive impairment, and was dependent on staff for all activities of daily living. The care plan and physician orders reflected full code status, with CPR to be initiated in the event of a cardiac or respiratory event. On the evening of the event, staff identified the resident as unresponsive after dinner. LPN #200 checked the resident, found no vital signs, and began chest compressions after checking code status and bringing the crash cart to the room. However, staff did not immediately call 911; the call was made only after compressions had already started. EMS records showed the 911 call was received at 8:06 P.M. and EMS arrived at 8:18 P.M. When EMS arrived, staff were performing chest compressions without ventilations. EMS documented that the resident had been without ventilations for greater than 12 minutes and then initiated ventilations with a bag valve mask while continuing resuscitation efforts. Interviews and record review showed that LPN #200 and LPN #216 performed chest compressions only and did not provide rescue breathing or ventilations during the code. LPN #200 stated the bag valve mask was not used because staff did not know how to use it and believed it was not on the crash cart, although the cart audit logs and observation showed bag valve masks and CPR mouth shields were present. The DON stated that if a code occurred, staff should call 911, apply the AED, and have one nurse provide ventilations while another performed compressions. EMS later pronounced the resident deceased after resuscitation efforts were stopped by physician direction.
RN lacked CPR certification with hands-on skills validation
Penalty
Summary
The facility failed to ensure that RN 2 maintained current CPR certification from a CPR provider whose training included a hands-on session in accordance with accepted national standards. During employee file review with the DSD, RN 2’s BLS certification was found to have been obtained from an online CPR provider, and the DSD stated she did not know whether the certification was entirely web based without the required in-person hands-on component. RN 2 later stated that the BLS course she completed was entirely online and consisted of reading materials, watching videos, and answering questions, with no hands-on component or requirement to demonstrate CPR skills. During a later interview, the DSD stated RN 2 needed to obtain BLS certification that included a hands-on component where skills are validated, and said this was necessary to ensure staff competency in performing CPR. Review of the facility’s CPR policy showed that staff were to maintain current CPR certifications through a provider whose training included a hands-on session in a physical or virtual instructor-led setting in accordance with accepted national standards, and that online knowledge components were acceptable only when in-person skills demonstration was also required.
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