Failure to Initiate CPR for a Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to initiate CPR for a resident who was documented as Full Code. Facility policy required staff to provide emergency basic life support, including CPR, to any resident needing such care, in accordance with physician orders and the resident’s advance directives. The resident was admitted with diagnoses including COPD, unspecified dementia, chronic kidney disease, and bilateral below-knee amputations, and had a physician’s order and care plan indicating Full Code status, with interventions to communicate the resident’s choice and provide CPR. On the morning of the incident, a nurse aide reported that the resident was not doing well, with an open mouth and no verbal response. An LPN assessed the resident around that time and documented normal vital signs, then returned to charting. Later, staff observed changes in the resident’s condition, including being cold and not breathing. A medication technician assessed the resident as cold and stiff and told staff the resident was dead. The aide asked whether CPR should be started, and the medication technician responded that nothing could be done. The LPN and RN did not know the resident’s code status at that moment and relied on the medication technician’s assessment instead of immediately verifying the code status and initiating CPR. The RN subsequently assessed the resident, found no heart rate or breath sounds, and confirmed that no one in the room performed CPR. Staff interviews revealed that the RN and LPN deferred to the medication technician, who also worked outside the facility as a deputy coroner, and that this influenced the decision not to initiate CPR despite the resident’s Full Code status. The resident’s daughter reported being informed by phone that her mother’s eyes were glazed and then shortly afterward that she was deceased, and stated that no CPR was given and that she overheard staff discussing not knowing the code status as the reason CPR was not performed. The medical director, regional nurse, interim DON, administrator, and county coroner all confirmed in interviews that staff did not follow the CPR protocol and that CPR should have been performed for a Full Code resident.
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