F0600

J

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

West Palm Beach, Florida Survey Completed on 03-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to honor a resident’s full code status and to provide ordered emergency care/CPR when the resident was found unresponsive. The resident was cognitively intact, had a tracheostomy and a feeding tube, required substantial/maximal assistance with activities of daily living, and was receiving hospice services. The resident’s care plan and physician’s orders documented an advanced directive of full code. Despite this, when the resident was found without chest rise and without vital signs, no CPR or emergency services were initiated.

On the night of the incident, a CNA working the 11P–7A shift found the resident unresponsive during initial rounds and immediately notified the RN assigned to the resident. The CNA then continued with her rounds. The RN assessed the resident, determined that the resident was not breathing and had no vital signs, but did not check the resident’s chart or electronic record for code status. The RN assumed the resident was a DNR because the resident was on hospice, and therefore did not initiate CPR or call 911. Instead, the RN called the physician, who instructed her to call hospice, and hospice was notified. A hospice nurse was dispatched, and post-mortem care was provided. The RN documented that the resident was found with no chest rising and no vital signs, that hospice was called, and that post-mortem care was provided, but did not document any attempt at CPR.

Another RN on the same 7P–7A shift returned from break around 12:30 AM and saw a hospice chaplain at the nurses’ station and the first RN charting. When he inquired, he was told that the resident had died. He observed on the computer screen that the resident was a full code and informed the first RN of this. Despite recognizing that the resident was a full code, he did not report the situation to anyone, continued his shift, and left the facility without notifying administration. The facility’s Regional Nurse Consultant later discovered, during chart audits of discharged residents, that no CPR had been performed on a resident with full code status and notified the Administrator. The Administrator, who also served as Abuse Coordinator, confirmed with the first RN that CPR and 911 had not been initiated. The facility’s abuse and neglect policy defined neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress, and included failure to report observed or suspected abuse or neglect as an example of neglect. The failure to perform CPR on a full-code resident and the failure of staff to report the incident to administration were identified as neglect.

The Immediate Jeopardy began when the resident was found unresponsive and no CPR or emergency services were initiated, despite the resident’s documented full code status. The facility’s own review and interviews established that the RN responsible for the resident did not verify code status and acted on an assumption based solely on the resident’s hospice enrollment. Additionally, the second RN, after learning that the deceased resident was a full code, did not report the occurrence to administration or take further action. These inactions, in the context of the facility’s abuse and neglect policy and the resident’s clearly documented wishes and orders, led to the determination of neglect and Immediate Jeopardy related to failure to provide basic life support according to physician’s orders and advanced directives.