Failure to Implement Full Code Advance Directive and Initiate CPR
Penalty
Summary
The deficiency involves the facility’s failure to implement a comprehensive care plan related to advance directives for one resident who had been admitted with diagnoses including COPD, unspecified dementia, chronic kidney disease, and bilateral below-knee amputations. The resident’s physician order and the Advanced Directives Comprehensive Care Plan identified the resident as Full Code, with goals to have the resident’s health care wishes honored and interventions that included communicating the resident’s choice and providing CPR. The facility’s policy required individualized comprehensive care plans with measurable objectives and timetables to meet residents’ needs, including honoring advance directives. On the day of the incident, a Kentucky Medication Technician (KMA) found the resident at approximately 10:25 AM not breathing and cold to the touch. The KMA called a Registered Nurse (RN) to the room, and the RN assessed the resident and found no heart rate, no breath sounds, and that the resident was cold to the touch. A progress note documented these findings but did not indicate that CPR was initiated, despite the resident’s Full Code status and the care plan intervention to provide CPR. A certified death certificate documented that the resident expired in the facility at 10:29 AM. Multiple staff interviews confirmed that CPR was not performed and that the resident’s care plan was not followed. The RN stated she did not know the resident’s code status, even though it was listed on the care plan, and acknowledged that staff failed to follow the care plan and perform CPR, relying instead on directions from the KMA, who also worked outside the facility as a deputy coroner. The KMA admitted she did not follow the care plan and did not verify the code status, call for help, obtain a crash cart, or begin CPR. Other staff, including an LPN, the MDS Coordinator, the Medical Director, the County Coroner, a Regional Nurse, the Interim DON, and the Administrator, all confirmed that staff did not implement the resident’s Full Code care plan by initiating CPR when the resident was found without pulse or respirations.
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