Failure to Honor Full Code Status and Initiate Timely CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a cognitively intact resident’s clearly documented Full Code status and to initiate CPR when the resident was found unresponsive. The resident had multiple medical diagnoses including type 2 diabetes, atrial fibrillation, abnormal gait, blindness in the right eye, shortness of breath, muscle wasting, mood disorder, and hypertension. On admission and throughout the stay, documentation in the EMR, physician orders, nursing assessments, care plan, and an APRN advance care planning note consistently identified the resident as Full Code, with the resident verbalizing understanding of Full Code versus DNR and electing Full Code. A 5‑day MDS showed intact cognition (BIMS 14), and progress notes shortly before the event documented the resident as clinically stable, at baseline, and continuing as Full Code. On the morning of the incident, a CNA assigned to the resident reported finding him unresponsive close to 6:00 a.m. and notified the LPN assigned to him. Another CNA reported being told around 5:30 a.m. that the resident was not responding and, upon entering the room, found the resident not breathing and without a pulse, partially hanging off the bed. Both CNAs described that when the LPN arrived, she checked the resident, left to obtain a pulse oximeter, returned with an oxygen saturation reading of 60, and was told by the CNA that there was no pulse and that a code should be called. The CNAs stated that the LPN delayed, left the room again to check code status, then reported the resident was Full Code, but still did not initiate CPR or call a code blue. Instead, the CNAs were sent to get another nurse from another floor, leaving the resident alone in the room during part of this time. The CNAs consistently reported that no staff initiated CPR before EMS arrived. The LPN assigned to the resident stated she found him unresponsive around 6:00 a.m., performed a sternal rub, noted he was not responding and that his feet were cold, and then left the room to call 911 from her personal cell phone and get the crash cart. She acknowledged that she did not start CPR, stating she believed the resident was already dead, that he was a large man, and that she needed a backboard and additional help to move him to the floor, but did not ask the CNAs to assist. She confirmed that no code blue was called and that no CPR was performed by facility staff. Two additional nurses who responded to the room reported they were summoned to “pronounce” a resident, assumed the resident was a DNR based on how the situation was presented, did not independently verify code status before acting, and did not initiate CPR. The RN who arrived stated she called the DON to ask what to do about pronouncing, was told the resident was Full Code and to start CPR, and that at that moment EMS arrived. EMS arrived at approximately 6:09 a.m., confirmed the resident’s Full Code status, questioned why CPR had not been started, and then initiated CPR, which continued for approximately 45 minutes before the resident was pronounced dead. Facility leadership and the Medical Director later confirmed that CPR had not been initiated by staff and that the resident’s Full Code status had not been honored, resulting in a determination of Immediate Jeopardy.
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