Failure to Ensure CPR per Code Status and Wound Care Coverage in Absence of Treatment Nurse
Penalty
Summary
The deficiency involves the facility’s failure to administer operations in a way that ensured effective and efficient use of resources to maintain residents’ highest practicable physical well-being, specifically in relation to CPR and code status verification. One resident with a physician’s order for full code status was found unresponsive, pulseless, and not breathing. Licensed nursing staff did not accurately determine this resident’s code status and failed to initiate and continuously provide CPR in accordance with the physician’s full code order until EMS arrived. When the hospice nurse arrived, no life-saving measures were in progress, and the resident was later pronounced deceased. The DON stated she had not identified this incident as deficient practice at the time it occurred and did not realize the magnitude of the problem until it was brought to her attention during the survey. The DON also acknowledged that the facility did not provide additional education to nursing staff on verifying code status and continuing CPR until EMS assumed responsibility. The facility’s administration, including the Administrator and DON, did not have an adequate system in place to identify this deficient practice, determine its root cause, or ensure that nursing staff were trained and competent in verifying residents’ code status and implementing CPR according to orders. The Administrator indicated that when it was discovered that the LPN had not properly determined the resident’s code status and had not continued CPR until EMS arrival, administrative staff should have reviewed the incident to determine the root cause and re-educated nursing staff on the CPR policy and procedure. However, this did not occur prior to the surveyors’ identification of the issue. As a result, the surveyors determined that an Immediate Jeopardy situation existed related to the failure to ensure CPR was initiated and continued for a resident with full code status. A second deficiency involved the facility’s failure to have an adequate system to ensure that licensed nursing staff were made aware of their responsibilities for wound care in the absence of a Treatment Nurse. Multiple residents with pressure ulcers did not receive wound care as ordered by their physicians on days when no Treatment Nurse was assigned. The Treatment Nurse stated that weekend nurses should perform wound care when a Treatment Nurse is not present. Several LPNs reported they did not provide ordered wound care to residents with Stage III and Stage IV pressure ulcers because they were not aware they were responsible for completing wound care on their assigned residents. The DON indicated that on specific dates without a Treatment Nurse, it was the RN Supervisor’s responsibility to remind floor nurses to complete wound care, and a communication sheet instructed the RN Supervisor to remind nurses to perform wound care and sign the Treatment Administration Record. The RN Supervisor stated it was an understood responsibility that floor nurses were responsible for wound care in the absence of a Treatment Nurse, but the interviewed LPNs’ statements showed they had not been effectively informed of this responsibility, resulting in missed wound treatments as ordered. Overall, the facility’s administrative systems did not ensure that critical clinical responsibilities—verifying and acting on residents’ code status with appropriate CPR, and providing ordered wound care in the absence of a Treatment Nurse—were clearly assigned, communicated, and carried out by nursing staff. The DON’s and Administrator’s own interviews confirmed that they had not identified the CPR incident as deficient practice at the time, had not conducted a root cause review, and had not re-educated staff on CPR procedures, and that the process for ensuring wound care coverage on days without a Treatment Nurse relied on informal understandings rather than a consistently implemented system, leading to missed treatments for residents with pressure ulcers.
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