F0726

J

Failure to Initiate CPR and Honor Full Code Status

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

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that nursing staff demonstrated competency in performing CPR and honoring a resident’s full code status. The resident involved had a documented physician progress note confirming that he understood the difference between full code and DNR and elected full code status. On the night of the incident, the resident was found unresponsive and without vital signs, yet facility staff did not initiate CPR. The facility’s LPN job description required current CPR certification and outlined responsibilities including directing CNAs, complying with policies and procedures, and participating in end-of-life care, but these expectations were not met in this event.

According to interviews, a CNA who was not assigned to the resident was informed by the assigned CNA that the resident was not responding and not moving. As they proceeded to the room, they encountered the LPN at the nurses’ station, notified her of the situation, and the LPN stated she was on her way but continued what she was doing. When the LPN entered the room, she applied an oximeter and obtained an oxygen saturation of 60, which she described as “kind of low.” The CNA reported telling the LPN that the resident “is not here” and asking if they needed to call a code. The LPN left the room to check the resident’s code status, returned and confirmed he was full code, but still did not initiate CPR. The CNA stated that no one called a code blue, no overhead page was made, and no staff began CPR before EMS arrived.

The LPN later stated she found the resident unresponsive, with cold feet and no response to sternal rub, and that she called 911, obtained the crash cart, and asked a CNA to get another nurse. She reported that she did not start CPR because she believed the resident was already dead, said she needed a backboard and help to move the resident due to his size, and did not ask the CNAs to assist. She acknowledged that she did not call a code, did not perform compressions, and that all staff present “did not do anything” while waiting for EMS. Other nurses who responded to the room, including an RN and another LPN, stated they did not start CPR, assumed the resident was a DNR based on how the situation was presented, did not verify the code status themselves, and did not call a code blue. The RN reported that she did not initiate CPR because she assumed the resident was a DNR and was focused on the idea that she was being asked to pronounce death, and only after contacting the DON did she learn the resident was full code and was told to start CPR, at which point EMS arrived. EMS personnel questioned why CPR had not been started if the resident was full code. The medical director stated that the expectation was that immediate CPR should be started for a full code resident and that nurses are not to pronounce death or rely on signs such as cold extremities, but instead should confirm code status and initiate CPR.