Failure to Initiate CPR and Verify Code Status for Full-Code Hospice Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide emergency basic life support, including CPR, to a resident who was a documented full code, and to activate the emergency response system in accordance with physician orders and the resident’s advance directives. Facility policy titled “Emergency Procedure–Cardiopulmonary Resuscitation” stated that if an individual is found unresponsive and not breathing normally, a licensed staff member certified in CPR/BLS shall initiate CPR unless there is a known DNR order or obvious signs of irreversible death. The policy also directed staff to briefly assess for abnormal or absent breathing, instruct another staff member to activate the emergency response system and call 911, verify the individual’s DNR or code status, and then initiate the basic life support sequence of chest compressions, airway, and breathing. Record review showed that the resident had a “RESIDENT/FAMILY CONSENT FOR CARDIOPULMONARY RESUSCITATION” form dated and signed by the resident’s representative, indicating that CPR should be performed in case of extreme emergency. Additional documentation, including an Order Summary Report and a handwritten physician’s telephone order, confirmed a code status of “Full Code,” meaning the resident had chosen to receive CPR in the event of cardiac arrest or pulselessness. The resident had been admitted with diagnoses including severe protein-calorie malnutrition, heart failure, and atherosclerotic heart disease, was receiving hospice care, and was documented on the MDS as independent with decisions regarding tasks of daily life, with no noted memory problem. On the date of the incident at approximately 5:20 a.m., a CNA found the resident unresponsive and reported this to the nurse. LPN #1 went to the resident’s room, found the resident in bed unresponsive, attempted to obtain a pulse and blood pressure without success, and observed no rise or fall of the chest and no breath sounds. Progress notes documented that the LPN observed the resident was not breathing and was unable to obtain any vital signs, and that she notified the hospice nurse, the resident’s primary healthcare provider, the resident’s representative, the DON, and the Executive Director. There was no documentation of initiation of CPR or activation of the emergency response system. During interview, LPN #1 stated she did not “run a code” because the resident was on hospice and she assumed hospice patients were DNR. She acknowledged that she did not verify the resident’s code status in the chart or electronic record and that she accessed the binder only to obtain the hospice telephone number. The facility’s investigation confirmed that LPN #1 failed to check the resident’s code status and failed to initiate the emergency CPR procedure for a resident who was a full code, resulting in the resident not receiving CPR or emergency services and subsequently expiring at the facility.
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