F0678

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Failure to Provide AHA-Compliant CPR to Tracheostomy-Dependent Full-Code Resident

Washington, District Of Columbia Survey Completed on 03-03-2026

Penalty

Fine: $85,666

Summary

Facility staff failed to accurately provide cardiopulmonary resuscitation (CPR) to a resident who was a full code and dependent on a tracheostomy, resulting in a deficiency cited under 42 CFR 483.24, F678, Cardiopulmonary Resuscitation. The facility’s CPR policy required adherence to American Heart Association (AHA) guidelines, including immediate initiation of CPR when an individual is found unresponsive with absent or abnormal breathing, continuous chest compressions at a rate of 100–120 per minute, provision of rescue breaths, and not leaving the person alone except when absolutely necessary to call for help. The AHA guidance referenced in the report also specified that CPR for a person with a tracheostomy involves 30 chest compressions followed by 2 breaths delivered via the tracheostomy tube using an Ambu bag or mouth-to-trach, and that if the tracheostomy tube is dislodged or blocked, it should be replaced or the stoma covered to provide rescue breathing.

The resident involved had multiple significant medical diagnoses, including acute respiratory failure with hypoxia, epilepsy, dysphagia following cerebral infarction, diabetes mellitus, and schizophrenia. The resident had a physician’s order for full code status and care plans identifying risks for respiratory and cardiac complications, with interventions such as administering medications and treatments as ordered, monitoring for signs and symptoms of respiratory and cardiac complications, and providing tracheostomy care and respiratory therapy services. An admission MDS indicated the resident was cognitively intact with a BIMS score of 13, had functional limitations in upper extremities but no lower extremity impairment, used a walker, required partial/moderate assistance for some transfers, and received oxygen, tracheostomy care, and respiratory therapy.

During night shift rounds at approximately 3:00 AM, the nurse supervisor (Employee #6) found the resident lying supine on the floor near the doorway, unresponsive, without a pulse or respirations, with the inner cannula of the tracheostomy tube dislodged. The nurse supervisor reported performing a brief assessment, confirming the absence of pulse and respirations, and initiating chest compressions for about three minutes but did not provide any rescue ventilation via the tracheostomy site using an Ambu bag or other method. Contrary to AHA guidance and facility policy that require not leaving a collapsed person who needs CPR, the nurse supervisor stopped CPR and left the resident alone to go to the nurses’ station to get help, stating she did not use the call light or shout for help because it was 3:00 AM and she did not want to wake other residents. She also initially called a “Rapid Response” rather than a “Code Blue,” despite the resident being pulseless and not breathing.

When the respiratory therapist (Employee #9) arrived in response to the calls, the resident was on the floor on his back with several people present who were not administering CPR. The respiratory therapist assessed that the resident was not breathing, retrieved the Ambu bag from the bedside, connected it to oxygen, and began chest compressions with one hand while providing rescue breaths with the other. The therapist observed that the tracheostomy tube was dislodged and on the floor and was able to reinsert it without incident before continuing CPR with assistance from another respiratory therapist. The DON later confirmed that staff are trained that a Code Blue is automatic when someone collapses and has no pulse or is not breathing. The evidence showed that staff actions deviated from AHA-based facility policy by leaving the resident during CPR, failing to provide appropriate rescue breathing via the tracheostomy, and initially calling a Rapid Response instead of a Code Blue for a pulseless, non-breathing resident, leading to the cited deficiency.

The resident was subsequently pronounced deceased at 3:51 AM after EMS arrived and continued advanced cardiovascular life support. The surveyors determined that these failures constituted an Immediate Jeopardy situation related to the provision of CPR under F678.