Failure to Initiate CPR for Full Code Resident Due to Incorrect Code Status Information
Penalty
Summary
The deficiency involves the facility’s failure to provide basic life support, including CPR, to a resident who was a documented Full Code prior to the arrival of emergency medical personnel. The resident, an elderly male with dementia, cerebral infarction (stroke), and COPD, was admitted under hospice services with orders that Hospice A be notified of any change in condition. His advance directives and physician orders identified him as Full Code with CPR to be initiated if his heart or breathing stopped. However, his MDS assessment and care plan did not document his Full Code status, and his code status was incorrectly listed as DNR in the code status binder at the nurse’s station. On the day of the incident, the resident’s vital signs were incompletely documented, with no blood pressure, temperature, pulse, or respirations recorded, although an oxygen saturation of 99% via nasal cannula was documented by LVN A in the afternoon. The resident had a BIMS score documented as staff-assessed, and a progress note indicated he was moderately impaired but able to make decisions regarding tasks of daily life. Later that day, CNA B found the resident unresponsive in bed while passing dinner trays, noting that his skin appeared yellow and he did not respond to touch or verbal stimuli. CNA B immediately informed LVN A that the resident was unresponsive and not breathing. LVN A reported that upon entering the room, she assessed the resident, took his pulse and blood pressure, but did not document the readings and could not recall them. She confirmed that the resident was unresponsive, warm to the touch, and without respirations or detectable airway movement. Despite the resident’s actual Full Code status in the medical record and hospice documentation, LVN A did not initiate CPR because she relied on the code status binder, which incorrectly listed the resident as DNR. She contacted the nurse practitioner and DON to report the resident’s death and misidentified the deceased resident as a different individual. Hospice A later confirmed that the resident had always been Full Code with their agency and that he had personally signed the Full Code documentation. The facility’s CPR policy required CPR to be performed if a resident did not show obvious signs of clinical death, but no CPR was initiated for this resident, and hospice was not notified at the time of death.
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