F0678

J

Failure to Initiate and Maintain CPR for Full-Code Resident Until EMS Arrival

Berwyn, Illinois Survey Completed on 03-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to initiate and continue CPR for a resident who was a full code and found unresponsive, and to maintain resuscitative efforts until EMS assumed care. Video surveillance showed that at approximately 6:58 AM, a CNA entered the unit, went directly to the resident’s room, opened and immediately closed the door, and left the unit. At about 7:17 AM, another CNA entered the room, then exited to get an LPN; the LPN briefly looked into the room and walked away while the CNA re-entered. Over the next several minutes, multiple staff, including CNAs and LPNs, intermittently entered and exited the room, with one CNA later reporting that the resident’s brief was off and there was feces and urine in the bed. Towels were observed being brought to the room and soiled linens removed, and large plastic bags were used to collect soiled items.

The crash cart was brought to the resident’s doorway at about 7:21–7:22 AM, but the video showed that the backboard, manual resuscitation bag, oxygen tank, and AED remained on the cart and were not brought into the room before EMS arrived. Between the time the crash cart was placed near the room and EMS arrival at approximately 7:29 AM, staff did not obtain a backboard, and there is no visual evidence of CPR being performed. The facility’s code blue documentation sheet attached to the crash cart for that date was requested but not provided for review. EMS documentation and paramedic interview indicated that upon arrival at the bedside, no CPR was in progress, no resuscitation equipment was in the room, and only one nurse was present speaking with the roommate. EMS immediately placed a backboard, initiated manual compressions, applied a mechanical chest compression device, and began bag-mask ventilations with oxygen.

Staff interviews were inconsistent with the video and EMS findings. One CNA stated she responded to the overhead code, called 911, and waited in the lobby, but video showed her earlier entry into the unit and room and later participation in handling soiled linens. An LPN reported that she performed chest compressions and switched with another LPN, but video showed her only briefly looking into the room, later bringing the crash cart to the doorway, and not re-entering the room until shortly before EMS arrival. The night-shift LPN gave multiple conflicting accounts, initially stating he initiated CPR and called 911, then later admitting he had been “running around trying to figure out what to do,” acknowledging that compressions should not be stopped before EMS takes over, and confirming that cleaning feces and wetness does not take precedence over CPR. The RN from the adjacent unit reported that CPR was in progress and that she participated, but video showed her only very brief entries into the room and primarily handing in towels and obtaining bags and linens. EMS and hospital records documented that the resident was pulseless, apneic, in asystole, and that CPR was initiated by EMS with no return of spontaneous circulation, with signs of rigor mortis noted in the jaw and one arm while the torso remained warm.

The American Heart Association adult BLS guidelines cited in the report emphasize early, high-quality CPR and prompt defibrillation, including starting compressions immediately, using a firm surface, minimizing interruptions, and continuing CPR until advanced care arrives. The surveyors concluded that the facility failed to ensure that CPR was initiated and continued for this full-code resident after she was found unresponsive and a code blue was called, and that resuscitative efforts were not maintained until EMS assumed care. This failure was determined to constitute Immediate Jeopardy and had the potential to affect all residents in the facility identified as full code.