Failure to Provide CPR According to Full Code Status and Physician Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide basic life support, including CPR, in accordance with a resident’s documented full code status and physician orders. The facility’s CPR policy required staff to provide basic life support prior to the arrival of emergency personnel, consistent with the resident’s physician orders and advance directives. The American Heart Association Basic Life Support Algorithm referenced in the report emphasized that high-quality CPR is the most critical part of basic life support and should continue until advanced medical providers arrive or the patient shows signs of life. For this resident, multiple documents, including a Louisiana Physician Orders for Scope of Treatment form, monthly physician orders, hospice certification and plan of care, and the comprehensive care plan, all indicated a full code status, requiring CPR if the resident was unresponsive, pulseless, and not breathing. On the day of the incident, the resident, who had diagnoses including hypertensive heart and chronic kidney disease with heart failure, stage 5 chronic kidney disease, and chronic obstructive pulmonary disease, was found unresponsive and not breathing. Surveillance footage showed that a CNA exited the resident’s room and quickly summoned the CNA supervisor, who then returned to the room and called for additional staff. Two LPNs entered the room shortly thereafter, but video review from the time the incident began until well after showed that no cardiopulmonary emergency equipment, such as a backboard, Ambu bag, or crash cart, was brought into the room. Documentation in a health status note by one of the LPNs stated that she was summoned to the room, found the resident unresponsive and not breathing, and that she attempted CPR but was unsuccessful, with the time of death later documented as pronounced by the hospice nurse. Interviews and video review, however, did not corroborate that CPR was initiated or continued as required. One LPN reported that when she assessed the resident, he had no pulse, was still warm, and showed no signs of prolonged death, but she did not discuss or verify the resident’s code status and assumed the resident was DNR because he was on hospice. She stated she was not aware the resident was full code and had not observed anyone performing CPR. The DON reported that the other LPN had initially believed the resident was DNR and admitted she had not yet implemented CPR; the DON then instructed her to return to the room and start CPR. The hospice nurse stated she was notified that the resident had expired and, upon arrival, found the resident in bed with a sheet over his head and no life-saving measures in progress. She was told that CPR had been started and stopped, but she did not instruct staff to stop CPR and expected it to continue until EMS or a physician directed otherwise. The facility was unable to provide evidence that any licensed nursing staff immediately verified the resident’s code status or ensured continuous CPR from the time the resident was found without a pulse and not breathing until the official time of death, resulting in an Immediate Jeopardy determination.
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