Inadequate CPR and Oxygenation for Full-Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate CPR and oxygenation to a resident who was a documented full code. The resident had multiple diagnoses, including hemiplegia and hemiparesis, cerebral infarction, type 2 diabetes, vascular dementia with behaviors, anxiety disorder, dysphagia, and a recent COVID-19 illness. The resident’s POLST and care plan clearly indicated full code status, with instructions that CPR would be initiated if the resident’s heart and respirations stopped. On the night in question, a CNA found the resident unresponsive and not breathing around 4:25 a.m. and notified the LPN, who confirmed the resident’s full code status, called 911, and went to the resident’s room to begin CPR. According to nursing progress notes and staff interviews, the LPN checked for a pulse, found none, and began chest compressions, then the CNA took over compressions while the LPN retrieved the crash cart and called 911. When the LPN returned, she resumed compressions and the CNA began bagging the resident. However, the ambulance run report and paramedic interview documented that upon EMS arrival, one staff member was performing chest compressions and another was attempting ventilation with a BVM that did not have a mask attached and was not connected to oxygen. The paramedic stated that the staff member had only the T-piece in the resident’s mouth and that proper oxygenation with a BVM requires application of the mask. The DON also confirmed that without the mask attached to the bag, adequate ventilation cannot be provided. EMS personnel further observed that staff stopped compressions when EMS entered the room to allow EMS to take over, and that the resident was cold to the touch with rigor mortis noted in the jaw. The LPN later acknowledged that the bed likely was not flattened during CPR and that she found the resident cold with no pulse, stating the resident had not just died minutes before. The facility’s CPR policy required provision of basic life support, including CPR, prior to EMS arrival, and specified the use of a face mask or resuscitator bag to ventilate two breaths after 30 compressions, with each breath delivered over one second to cause chest rise. Despite this policy, the staff’s use of a BVM without a mask and without oxygen, and the failure to ensure proper setup for effective ventilation, resulted in CPR that did not provide adequate oxygenation to the resident.
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