Failure to Provide AHA-Compliant CPR to Tracheostomy-Dependent Full-Code Resident
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.
Removal Plan
- Remove Employee #6 from resident care pending investigation and re-education.
- Re-educate all licensed nurses on AHA CPR/BLS requirements.
- Re-educate all licensed nurses on performing continuous chest compressions without leaving the resident.
- Re-educate all licensed nurses on proper ventilation for residents with tracheostomies (use of Ambu bag via trach; management of dislodged trach).
- Re-educate all licensed nurses on clear differentiation between Code Blue and Rapid Response.
- Include in education: 30 compressions at 100-120/minute.
- Include in education: rescue breathing via tracheostomy.
- Include in education: procedure if tracheostomy becomes dislodged.
- Require all licensed staff to maintain current AHA BLS certification.
- Implement mock Code Blue drills.
- Post Code Blue vs Rapid Response criteria at nurses' stations.
- Conduct an immediate 100% chart audit of all residents with physician orders for fall/safety assessments to verify appropriateness and implementation.
- Verify all physician orders for fall/safety assessments on MAR/TAR are being implemented.
- Address any missing documentation for ordered assessments.
- Re-educate nurses on required documentation of ordered assessments.
- Conduct a 100% audit of care plans for residents at risk for falls and update them to include more than one individualized, multi-factor fall prevention intervention.
- Provide education on care plans, Code Blue vs Rapid Response, CPR response and compliance, and physician orders/implementation of fall/safety assessments.
- Provide education by the educator/designee for all licensed staff starting night shift.
- Provide education for all other licensed staff prior to or at the start of their shift.
- Continue training until all licensed staff have been educated.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to maintain documentation that 14 of 41 licensed nurses had current CPR certification for Healthcare Providers. CPR cards were not available for several RNs and LPNs, and the NHA and DON confirmed the facility did not ensure these nurses maintained current CPR certification in accordance with accepted national standards.
An agency CNA found a full code resident unresponsive, but an agency RN did not check for a pulse or vital signs and did not start CPR before leaving to call EMS and look for help. Staff present were not CPR certified, and EMS arrived to find the resident pulseless and apneic with no CPR started by the facility. The resident later died at the hospital.
Facility staff failed to ensure that an LPN and a CNA maintained current CPR certification while working scheduled shifts. Interviews with the Administrator, DON, and HR Director confirmed that RNs, LPNs, and CNAs were expected to hold active CPR cards, and record review showed the LPN’s CPR had expired before renewal while the CNA could not produce a valid CPR card for the employee file. Staffing schedules showed both employees worked multiple shifts despite the lapse, and the job descriptions for both roles required current CPR certification.
A full-code resident with atrial fibrillation, liver cirrhosis, and osteomyelitis was found unresponsive after a family member alerted staff to breathing trouble. Staff entered the room without emergency equipment, and CPR was not started promptly; records and interviews showed delays in recognizing the emergency, calling Code Blue/911, and bringing in the AED, AMBU bag, and crash cart. The resident later expired, and the death certificate listed myocardial infarction as the cause of death.
LPNs and RNs did not maintain current CPR certification for Healthcare Providers with a required hands-on component. Facility policy required active CPR certification for licensed nurses, but review of certification cards showed that 16 of 33 licensed nurses had only online-only CPR training for non-healthcare providers. The HR Director, NHA, and DON confirmed the deficiency.
A resident with CHF was found unresponsive and CPR was performed even though the chart contained an active DNR order, an MDS indicating DNR, and a POLST choosing DNR and allowing natural death. LN stated she reviewed the physician order at the time and confirmed the resident was DNR, and the DON confirmed the resident's orders and POLST indicated DNR.
Missing Current CPR Certification for Licensed Nurses
Penalty
Summary
The facility failed to maintain documentation that its nursing personnel had current education and certification to provide basic life support, including CPR, prior to the arrival of emergency medical personnel and subject to physician orders and residents’ advance directives. A review of the facility’s CPR policy showed it was intended to ensure timely and appropriate initiation of CPR by licensed nursing staff in accordance with facility policy, resident rights, and federal and state regulations. During the survey, the facility provided a list of 41 currently employed licensed nurses and copies of CPR certification cards for review. CPR certification cards were not available for RN Employees E3, E4, E5, E6, and E7 and LPN Employees E8 through E16, totaling 14 of 41 licensed nurses. In an interview, the Nursing Home Administrator and the DON confirmed that the facility failed to ensure these nursing personnel maintained current CPR certification for Healthcare Providers through a CPR provider whose training included a hands-on session in a physical or virtual instructor-led setting in accordance with accepted national standards.
Failure to Start CPR for Full Code Resident
Penalty
Summary
The facility failed to assess a resident for a pulse or vital signs and failed to immediately start CPR for a resident who was a full code and was found unresponsive. Resident #60 had diagnoses including multiple fractured ribs on the left side, acute respiratory failure with hypoxia and hypercapnia, type 2 diabetes mellitus with diabetic peripheral angiopathy, CHF, PVD, osteoarthritis of the left knee, and atherosclerotic heart disease of the native coronary artery. The resident’s code status was documented as full code, and the care plan stated CPR should be started and EMS called if needed. According to the CCTV timeline and staff statements, an agency CNA found the resident unresponsive during rounds and summoned nursing staff. An agency RN arrived at the room, briefly entered, and then left without taking vital signs, checking for a pulse, or starting CPR. The RN then went to the nurses’ station and made calls while the resident remained without CPR. Other agency CNAs were present, but they were not CPR certified. EMS arrived several minutes later and found the resident unresponsive, pulseless, and apneic, with no evidence that facility staff had started CPR before EMS arrival. The 911 audio, CAD log, EMS report, police report, and witness statements all reflected that the resident was found unresponsive and that the facility did not initiate CPR. The police officer reported staff were standing in the room and did not know what to do, and EMS reported the facility staff did not start CPR and did not know the approximate down time. The hospital record stated the resident had been found unresponsive by nursing facility staff, no CPR had been performed by the facility for over ten minutes, and EMS initiated CPR and ACLS during transport. The resident was later pronounced dead at the hospital.
Failure to Maintain Current CPR Certification for Nursing Staff
Penalty
Summary
The facility failed to ensure that a nurse and a CNA maintained current CPR certification while working in the facility. Surveyor interviews and record review showed that facility leadership and HR stated that RNs, LPNs, and CNAs were required to have active CPR certification, and that CPR was needed because staff would respond during a code until EMS arrived. Despite this, the surveyor was unable to obtain a current CPR certification card for a CNA after multiple requests to the Administrator, Assistant Administrator, and DON, and the HR Director stated that the CNA had not produced a valid CPR certification for the employee file. Record review also showed that an LPN had worked multiple night shifts while her CPR certification had expired. The LPN confirmed receiving an HR email about the expiration and stated she renewed her CPR certification on the day of the interview. The expired CPR certificate showed the prior certification had lapsed before the renewal date. The HR Director stated she had sent an email about the upcoming expiration but did not follow up after returning from medical leave. Daily staffing schedules showed that the LPN and CNA worked multiple shifts during the review period despite not having active CPR certification. The facility’s job descriptions for both LPNs and CNAs stated that current CPR certification was required. The facility census report showed 149 residents in the facility at the time of the survey.
Delayed CPR Initiation for Full-Code Resident
Penalty
Summary
The facility failed to initiate CPR in a timely manner for a resident who was full code and found unresponsive. The resident had diagnoses including atrial fibrillation, liver cirrhosis, and osteomyelitis of the right ankle and foot, and the MDS documented moderately impaired cognition. The medical orders, MOLST, and care plan all documented full code/CPR status. Surveillance video showed that after a family member alerted staff that the resident was unresponsive, RN #11 and PCT #5 entered the room without emergency equipment. RN #12, the Assistant DON, later entered the room without equipment, and no medical equipment was observed being brought to the room for several minutes. The video also showed multiple staff entering and exiting the room over time, with the AED, AMBU bag, cardiac board, and crash cart not brought in until much later. The Code Blue/CPR worksheet documented CPR as initiated at 7:01 PM, while other records and staff statements reflected delays and inconsistent times for when the resident was found, when CPR began, and when EMS was called. Staff interviews described that the resident was breathing slowly at first, then became unresponsive, with inability to obtain a pulse or blood pressure. PCTs stated they notified RN #11 after the family member reported trouble breathing, and one PCT stated RN #12 said the resident had already passed away before CPR began. RN #14 stated they responded to an overhead Code Blue and saw RN #12 performing CPR, while the DON later stated the facility’s investigation found CPR was not initiated until RN #13 entered the room. The resident expired at 7:22 PM, and the death certificate listed myocardial infarction as the cause of death.
LPNs and RNs Lacked Acceptable CPR Certification
Penalty
Summary
Facility nursing personnel did not maintain current CPR certification for Healthcare Providers through a CPR provider whose training included a hands-on session either in a physical or virtual instructor-led setting in accordance with accepted national standards for 16 of 33 licensed nurses. The affected staff included LPNs E1 through E12 and RNs E13 through E16. The facility policy titled Cardiopulmonary Resuscitation CPR stated that licensed nurses, respiratory therapists, and van drivers must hold active CPR certification for healthcare providers, and that online-only courses were not acceptable. Review of the CPR certification cards for the 16 licensed nurses showed that their certification was from an online-only CPR class for non-healthcare providers and did not include a hands-on session. During an interview, the Human Resources Director confirmed that these employees did not have the appropriate CPR certification for licensed nurses. The Nursing Home Administrator and the DON also confirmed that the facility failed to ensure that facility nursing personnel maintained current CPR certification for Healthcare Providers through a CPR provider whose training included a hands-on session either in a physical or virtual instructor-led setting.
CPR Performed Despite Active DNR Order
Penalty
Summary
The facility failed to confirm the code status of Resident 96 during an emergency when LN 3 performed CPR after the resident was found unresponsive. Resident 96 had been readmitted with a diagnosis of congestive heart failure, and the record showed an active physician order for DNR, along with an MDS assessment and POLST indicating DNR and allowing natural death to occur. During interview, LN 3 stated CPR was performed after Resident 96 was found unresponsive and that she reviewed the physician order at that time and confirmed the resident's code status was DNR. The MDS Coordinator confirmed the POLST and MDS assessment indicated DNR, and the DON confirmed the OSR showed an active DNR order and stated the physician's order and POLST were expected to be carried out correctly; otherwise, the resident's wishes were not honored.
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