F0726

D

Failure to Provide Competent CPR and Ensure Continuous Anticonvulsant Therapy

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

Penalty

Fine: $85,666

Summary

Facility staff failed to demonstrate appropriate competencies and skill sets in providing safe emergency care to a resident who was a full code with a tracheostomy. The resident had multiple diagnoses including acute respiratory failure with hypoxia, epilepsy, dysphagia following cerebral infarction, diabetes mellitus, and schizophrenia, and received oxygen, tracheostomy care, and respiratory therapy services. During a night shift supervisor round at approximately 3:00 AM, the nurse supervisor found the resident on the floor near the doorway, lying supine, unresponsive, without a pulse or respirations, and with the inner cannula of the tracheostomy tube dislodged while the oxygen tubing remained connected.

The nurse supervisor reported that she performed a brief assessment, checked for pulse and respirations, and initiated CPR. She stated she provided chest compressions for about three minutes but did not provide ventilations via the tracheostomy site using an Ambu bag or any other form of rescue breathing, despite the facility’s CPR policy referencing American Heart Association (AHA) guidelines that include providing breaths after chest compressions. Instead of immediately calling for help from the resident’s room, she left the unresponsive resident alone to run to the nurse’s station to get assistance, explaining that 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 further stated that she initially called a “Rapid Response” rather than a “Code Blue,” even though the resident was unresponsive, pulseless, and not breathing, and she had already been performing CPR without response.

These actions were inconsistent with the facility’s Emergency Procedure – Cardiopulmonary Resuscitation policy, which directed staff to immediately activate the emergency response system (Code Blue), call 911, and provide CPR in accordance with AHA guidelines, including chest compressions and rescue breaths. The evidence showed that staff did not immediately activate a Code Blue, did not promptly call for help from the scene, and did not accurately provide CPR, specifically failing to provide ventilations via the tracheostomy site. The resident was later pronounced deceased at the hospital. Review of the nurse supervisor’s file showed she had been certified/trained in CPR/Basic Life Support using AHA guidelines, yet the care provided did not follow those guidelines.

Facility staff also failed to ensure that another resident consistently received an ordered anticonvulsant medication, Lacosamide 200 mg, prescribed twice daily for seizure precaution. This resident had diagnoses including convulsions, hypertension, spastic hemiplegia affecting the left dominant side, and an active diagnosis of epilepsy with status epilepticus, and the care plan directed staff to give seizure medication as ordered and monitor effectiveness. A controlled substance record showed that the last available dose from one supply was administered on a specific date at 10:00 PM, with the count then at zero. The prescription for Lacosamide was written on a later date but was not faxed to the pharmacy until several days afterward, contrary to facility policy requiring refills to be reordered at least three days before the last dose.

During the period when the resident should have been receiving Lacosamide, the Medication Administration Record (MAR) showed multiple entries where the medication was not administered, documented with codes indicating “hold/see progress notes” or “other/see progress notes.” On several later dates, an LPN documented on the MAR that Lacosamide 200 mg was administered at 10:00 PM, but there was no corresponding documentation that the medication had been removed from the Omnicell or delivered from the pharmacy, and the controlled drug disposition form showed no doses available after the earlier date. At the same time, Omnicell inventory records showed that six Lacosamide 200 mg tablets were in stock and available in the facility, yet they were not used for the resident. The resident experienced seizures, including one episode after smoking and another associated with a change in mental status, leading to rapid responses and transfers to the hospital. The physician was not made aware that the resident had missed multiple doses of Lacosamide, despite the missed administrations documented on the MAR.