F0678

J

Failure to Honor Full Code Status and Initiate CPR for Unresponsive 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 provide basic life support/CPR in accordance with a resident’s documented full code status and physician orders. Facility policy required that CPR be provided to all residents in cardiac arrest unless there was a fully executed DNR order, and that in the absence of such an order, the nurse must immediately begin CPR and continue until EMS assumed responsibility. The policy also required two nurses to verify resident identification and the presence of a fully executed DNR order in the advanced directive section of the medical record. In this case, the resident had a care plan and a physician’s order specifying full code status, and there was no documentation of a DNR order.

Record review showed that the resident was cognitively intact, required substantial/maximal assistance with ADLs, had a tracheostomy and a feeding tube, and was receiving hospice services. The hospice nurse reported that the resident was alert, oriented, and personally chose to be full code, and that hospice honored residents’ decisions to remain full code. Despite this, when the resident was found unresponsive, the required verification of code status and initiation of CPR did not occur. A CNA working the night shift found the resident unresponsive at the start of her shift and immediately notified the RN assigned to the resident, then continued her rounds.

The assigned RN stated that upon being notified, she assessed the resident around 11:15 PM, found no breathing and no vital signs, but did not check the chart for code status and did not initiate CPR or call 911. She reported that she assumed the resident was DNR because the resident was on hospice, and instead called the physician, who told her to call hospice, and then she called hospice. A progress note later documented that the resident was found with no chest rise and no vital signs, hospice was called, a hospice nurse was dispatched, and post-mortem care was provided. Another RN on the same shift stated that when he returned from break around 12:30 AM, he saw a hospice chaplain at the nurses’ station and observed the first RN charting; when told the resident had died, he saw on the computer that the resident was full code and informed the first RN of this, but he did not report the situation to anyone and continued his shift. The facility later identified that no CPR or emergency services were initiated for a resident with a full code order, and the resident died.

The facility determined that Immediate Jeopardy began when the resident was found unresponsive and no CPR was initiated, and that the noncompliance involved failure to follow the advanced directive and CPR policies and procedures. Interviews with leadership confirmed that the expectation was for licensed nurses to follow facility policy and perform CPR in the absence of DNR orders, and that in this incident, those expectations were not met. The root cause analysis identified failure to follow the Advanced Directive Policy and Procedure as the cause of the noncompliance.