F0678

J

Failure to Honor Full Code Status and Initiate CPR for Unresponsive Resident

Pinellas Park, Florida Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to honor a resident’s clearly documented Full Code status by not initiating CPR when the resident was found unresponsive. The resident had multiple 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, the resident had no DNR order, was documented as alert, oriented, able to follow instructions, and capable of making healthcare decisions. Advance Care Planning notes from an APRN and a physician documented that the resident understood the difference between Full Code and DNR and elected/confirmed Full Code status. The admission evaluation, care plan, and subsequent physician notes all consistently reflected a Full Code status, and the resident’s cognition was documented as intact with a BIMS score of 14.

On the night of the incident, CNAs and nursing staff described discovering the resident unresponsive in the early morning hours. One CNA reported being told by another CNA that her resident was not responding around 5:30 a.m. and, upon entering the room, found the resident not breathing and without a pulse. The CNA stated that the LPN assigned to the resident was notified but did not immediately come to the room, and when she did arrive, she used a pulse oximeter that showed an oxygen saturation of 60. The CNA reported that she repeatedly questioned the need to call a code and start CPR, but the LPN left the room to check the resident’s status and did not initiate CPR. The CNAs then went to obtain another nurse from another floor, leaving the resident alone in the room for a period of time. When they and additional nurses returned, the CNA reported that no one was performing CPR, no code blue was called, and 911 had not yet been contacted until directed by another RN.

The LPN assigned to the resident stated that when notified by the CNA around 6:00 a.m., she found the resident unresponsive, with cold feet and no response to a sternal rub. She reported calling 911 from her personal cell phone at 6:04 a.m. and obtaining the crash cart, but acknowledged that she did not start CPR, stating she believed the resident was already dead, that he was a large person, and that she needed a backboard and help to move him to the floor. She also stated that she did not ask the CNAs to help move the resident and that no compressions were performed by her or the other nurses who arrived. Other nurses who responded to the scene reported that they were summoned under the impression that a resident needed to be pronounced dead, assumed the resident was a DNR, did not verify the code status themselves, did not call a code blue, and did not initiate CPR. The Medical Director later confirmed that the expectation for a Full Code resident found unresponsive was immediate initiation of CPR prior to EMS arrival and agreed that staff failed to honor the resident’s wishes for resuscitation. The surveyors determined that CPR was not initiated for approximately 35 minutes, resulting in physical pain and ultimate death for the resident and leading to an Immediate Jeopardy finding.

Facility policies in place at the time required staff to follow American Heart Association guidelines for CPR, to provide basic life support including CPR prior to EMS arrival in accordance with the resident’s advance directives, and to ensure CPR-certified staff were available at all times. The policies also required clear communication of code status and adherence to residents’ rights to formulate advance directives. Despite these policies and the resident’s clearly documented Full Code status, staff did not call a code blue overhead, did not promptly verify and act on the code status, and did not initiate CPR while waiting for EMS. EMS personnel, upon arrival, questioned why CPR had not been started for a Full Code resident and then initiated resuscitative efforts themselves. The surveyors concluded that the failure to initiate CPR and honor the resident’s advance directive for end-of-life care created a situation that resulted in a worsened condition and the likelihood of serious injury and/or death, and they cited this as an Immediate Jeopardy deficiency.