Failure to Provide Required CPR and Activate EMS for Full Code Resident
Summary
The deficiency involves the facility’s failure to provide immediate and appropriate basic life support, including CPR, to a resident with a documented full code status when the resident was found unresponsive. The resident had diagnoses including a slow-progressing circulatory condition involving narrowing or blockage of vessels, a condition that restricts airflow and makes breathing difficult, and other listed conditions. The physician’s order specified “Full Code,” and the care plan documented that the resident was under court-ordered guardianship with wishes honored as full code. The facility’s policy required that in the event of cardiac or respiratory arrest, staff immediately call for assistance, overhead page a code, begin CPR in the absence of a valid DNR, and continue CPR until EMS assumes responsibility or the resident responds. On the night of the incident at approximately 2:00–2:07 a.m., a CNA found the resident unresponsive in bed and notified the RN on duty. One CNA’s written statement indicated that the RN said she already knew the resident was going to die and instructed the CNA to clean and cover the resident. Another CNA’s account stated that the RN came to the room, took vital signs, and then instructed her to clean the resident. The RN’s own written statement and interview indicated that she called a code blue, that an LPN brought the crash cart, and that they performed CPR for approximately 20 minutes. The LPN’s statement corroborated that a code blue was called, that he brought the crash cart, and that CPR was performed for about 20 minutes before the RN stopped and stated that the resident was gone or words to that effect. The RN acknowledged that the resident had no vital signs but was warm and not responding, and she stated that she believed the resident was on hospice and therefore did not call 911. After CPR was discontinued, the RN did not activate EMS and instead notified the DON, the provider, and the resident’s family. The DON documented receiving a message from the RN that the resident had no pulse and no blood pressure and that the assigned nurse had initiated CPR but was unable to revive the resident. The DON later received a text from the RN that the resident had expired. The DON stated that at approximately 6:00 a.m. she called the facility and asked if 911 had been called, and upon learning it had not, she instructed the RN to call 911. The RN then reinitiated CPR at around 6:00 a.m., approximately four hours after the resident was first found without pulse or respirations, and stated that they tried to do something until EMS arrived because EMS had to see them doing CPR. EMS records showed activation at 6:18 a.m., arrival at 6:27 a.m., and pronouncement of death at 6:31 a.m., with documentation that CPR was not attempted by EMS because it was considered futile and that the resident exhibited postmortem changes. The Medical Director confirmed that the resident was full code and stated that staff should have started CPR and called 911 and that CPR should not be done four hours after a resident is pronounced dead. The facility’s investigation and a root cause analysis concluded that the RN and LPN did not follow the facility’s established policy and procedure to call 911 and administer CPR to a full code resident until EMS arrival. The root cause was identified as the nurse’s belief that the resident was on hospice and her failure to check the resident’s code status as outlined in facility policy. The surveyors determined that the failure to immediately activate EMS and to continue CPR until EMS arrival for this full code resident constituted noncompliance with the requirement to provide basic life support and resulted in an Immediate Jeopardy determination.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied. Resident #1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All codes to 1.1.26 were reviewed to ensure protocol was followed. No outliers were noted. All licensed nurses received education from the Director of Nursing and/or nursing management on [R] policy and procedure and Florida [R] policy. This includes where to find the code status. Education addressed what to do for full code hospice residents. Education completed with CNA's that protocol is that they do not assist with [R] or breaths during a [R] event. All education will be added to new hire orientation. Code drills will occur 3 x weekly x 4 weeks, followed by 2 x weekly x 4 weeks, followed by 1 x weekly x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Educated licensed nurses on CPR policy and procedure and Florida Do Not Resuscitate (DNRO) policy, including where to find code status and what to do for full code hospice residents; emphasized initiating emergency services immediately when resident is full code, continuing CPR until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS.
- Implemented emergency response “Code Blue” drills on all three shifts, including full code and full code hospice scenarios, with emphasis on calling 911 immediately.
- Educated licensed nurses and CNAs on the facility abuse and neglect policy, including resident rights.
- Required licensed nurses to complete a CPR post-test; restricted staff who have not completed education/testing from working until completion.
- Educated licensed nurses regarding change in condition.
- Placed laminated instructions on how to overhead page during a code at all nursing station phones and other designated phones.
- Held a Quality Improvement Performance Committee meeting to review root cause analysis findings and approve recommendations.
- Held a Quality Improvement Performance Committee meeting to review progress of the plan and approve recommendations.
- Completed a “like resident” audit of all expired residents and rehospitalizations for a defined period to determine whether involved staff were the same as the code event and whether proper procedure was followed.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to maintain accurate and complete crash cart audits for multiple full-code residents. Surveyors, accompanied by the DON, found that daily crash cart checks did not include verification of supply expiration dates, and that an extension cord documented as present on several audit dates was not actually in the cart. Audit logs also conflicted with the cart’s contents by indicating that required items such as eye protection, saline, and clear plastic were present when they were not. These findings were inconsistent with the facility’s policy requiring the crash cart to be checked every 24 hours and after each use, with prompt replacement of equipment and supplies.
Surveyors found that several nurses lacked proper CPR certification required to support residents with full code status. Some LPNs and an RN had no CPR certification documented in their personnel files, while other LPNs held CPR cards that, although covering adult, child, infant, and AED use, did not specify BLS or healthcare provider-level training. The DON confirmed these gaps, which were inconsistent with facility policies requiring verification of necessary licenses and certifications at hire and ongoing BLS CPR certification for key clinical staff involved in resuscitative efforts.
Surveyors found that the AED on the Rehab Hall crash cart had no pads attached and no pads stored in the AED compartments or in the crash cart, despite daily checks being documented on a crash cart checklist that did not include verification of AED function or pad availability. During the observation, the ADON confirmed that no AED pads were readily available. The facility reported that this crash cart and AED would be used in an emergency for 18 of 19 residents on the Rehab Hall who were identified as Full Code.
Three staff members, including a CNA, an RN, and an LPN, were found to be working without current CPR certification, as confirmed by personnel file reviews and staff interviews. The DON was aware of some expired certifications, and all three staff continued to work shifts despite the facility's policy requiring current CPR certification.
A resident with multiple serious medical conditions and a full code status was found unresponsive and exhibiting signs of death. Staff failed to immediately initiate CPR, with delays caused by uncertainty, lack of certification, and panic. When CPR was started, it was performed ineffectively and without proper equipment or technique, as confirmed by EMS upon arrival. Facility policy requiring immediate CPR for full code residents was not followed.
A resident with complex medical conditions had a signed Advance Directives Form indicating DNR CC-A, but the physician order listed the resident as full code for two months before being corrected. The DON confirmed the mismatch between the resident's documented wishes and the code status order, contrary to facility policy.
Inaccurate Crash Cart Audits and Missing Emergency Equipment
Penalty
Summary
The facility failed to ensure accurate and complete crash cart audits for residents requiring basic life support, affecting eighteen of thirty-five residents who were designated as full code. During an observation of the crash cart with the DON, surveyors found that the daily audit documentation for the month did not include verification of expiration dates for crash cart supplies. Review of the crash cart audit logs showed that an extension cord was documented as being in the cart on multiple dates, but the extension cord was not present in the cart at the time of inspection. Additionally, the audit documentation indicated that required items, including eye protection, saline, and clear plastic, were not present in the crash cart, yet they were documented as being in the cart. The facility’s undated “Emergency Crash Cart” policy stated that the crash cart is to be checked every 24 hours and after every use, and that equipment and supplies are to be noted and replaced promptly, but the observed documentation and contents of the cart did not match these requirements. This deficiency was verified with the DON at the time of the survey and was cited under the requirement that personnel provide basic life support, including CPR, to residents requiring emergency care, subject to physician orders and advance directives, and was investigated under Complaint Number 2687380.
Plan Of Correction
Cridersville Care Center Provider Number:366171 Survey Type: Complaint Survey Survey Date: 04/29/26 This Plan of Correction (PoC) outlines the actions completed by the facility with regards to the deficiency citation. This Plan of correction does not constitute any admission of guilt or liability by the facility and is submitted only in response to the regulatory requirements. Please accept the following as the facility's credible allegation of compliance as of 4/30/26. F678 CPR All Full Code residents #18 have the potential to be affected by the alleged deficiency. On 4/27/26 the DON/ADON re-stocked the crash cart per the inventory sheet for all missing items. Crash cart inventory sheet updated and new one will go into effect on 5/1/26. All licensed nursing staff provided with training related to crash cart inventory being a daily audit review using inventory sheet on 4/27/26 per DON/designee. The DON/designee will conduct clinical rounds and conduct a random audit of crash cart three times per week for 4 (four) weeks to ensure compliance. The results of the audit will be documented. The facility conducted an Ad-Hoc QAPI meeting on 4/27/26 and discussed the alleged deficiency and corrective actions. Date when corrective action will be completed: 4/30/26
Failure to Ensure Nursing Staff Held Proper BLS CPR Certification
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff held appropriate and current Cardiopulmonary Resuscitation (CPR) certification consistent with facility policy and the needs of residents who had elected full code status. Surveyors reviewed personnel records and found that multiple nurses, including several LPNs and an RN, either had no CPR certification on file or held CPR cards that did not specify Basic Life Support (BLS) or healthcare provider-level training. Specifically, LPNs with certain hire dates had no CPR certification in their files, and an RN also lacked any documented CPR certification. Other LPNs possessed CPR cards that covered adult, child, infant, and AED use, but the cards did not indicate that the training was BLS or designated for healthcare providers. The Director of Nursing confirmed during interview that several identified staff members had no current CPR certification on file and that others had CPR certifications that did not include BLS or healthcare provider designation. Facility policy on Licensure, Certification, and Registration of Personnel required staff who need a license or certification to present verification to Human Resources prior to or upon employment. Another policy on Emergency Procedure Cardiopulmonary Resuscitation required key clinical staff, including non-licensed personnel who would direct resuscitative efforts, to obtain and maintain American Red Cross or American Heart Association certification in BLS CPR. These findings affected residents who had chosen full code status, as the facility did not ensure that staff responsible for providing resuscitation met the specified CPR certification requirements.
AED on Rehab Hall Crash Cart Lacked Pads for Full Code Residents
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure an Automated External Defibrillator (AED) was ready for use for residents requiring basic life support, including CPR, prior to the arrival of emergency medical personnel. During an observation of the Rehab Hall crash cart with the ADON, the AED was found lying on top of the crash cart with no pads connected, and no pads were located in the AED compartments or in the crash cart. The crash cart had a daily checklist of items, all of which were marked as checked, but there was no checkbox to verify the AED’s working order or the presence of pads. In an interview at the time of the observation, the ADON confirmed that no AED pads were readily available. The facility reported that 18 of the 19 residents on the Rehab Hall were designated as Full Code and that this crash cart and AED would be used in the event of an emergency or code situation. This deficiency was investigated under Complaint Number 2725566. No additional resident-specific medical histories or conditions at the time of the deficiency were provided beyond the facility’s identification of 18 Full Code residents on the Rehab Hall.
Failure to Maintain Current CPR Certification Among Nursing Staff
Penalty
Summary
The facility failed to ensure that three out of five sampled staff members, including a CNA, an RN, and an LPN, maintained current certification in Cardio-Pulmonary Resuscitation (CPR). Personnel file reviews revealed that these staff members' CPR certifications had expired, and interviews confirmed that they were not currently certified. Despite this, all three staff members continued to be scheduled and actively worked shifts throughout the facility. The Director of Nursing (DON) acknowledged awareness of the expired certifications for the CNA and RN but was not aware of the expiration date for the LPN. Facility policy required staff to be properly trained and/or certified in CPR to provide basic life support until emergency medical services arrived, and to maintain current CPR certification. The deficiency was identified through review of personnel files, staff interviews, and facility policy, and was investigated under a specific complaint number.
Failure to Initiate Immediate and Effective CPR for Full Code Resident
Penalty
Summary
A deficiency occurred when staff failed to initiate immediate and appropriate cardiopulmonary resuscitation (CPR) for a resident with a full code status who was found unresponsive. The resident, an elderly male with multiple significant diagnoses including end stage renal disease, dementia, severe sepsis, and metabolic encephalopathy, was noted to be dependent on staff for all activities of daily living and had severely impaired cognition. On the evening in question, the resident was last observed in the dining room and later found unresponsive, cold to the touch, with blue fingertips and signs of rigidity by two certified nursing assistants (CNAs). Upon discovering the resident's condition, the CNAs sought assistance from a registered nurse (RN), who appeared panicked and did not immediately initiate CPR. The RN left the room to verify the resident's code status and retrieve the crash cart, during which time no resuscitative efforts were started. When additional nursing staff arrived, chest compressions were eventually initiated, but not until several minutes had passed. The staff performing CPR were not all currently certified, and the compressions were described as ineffective by emergency medical services (EMS) personnel upon their arrival. No airway management or use of an automated external defibrillator (AED) was observed, and the resident was not placed on a hard surface for compressions. EMS personnel noted that the resident exhibited signs of rigor mortis and had likely been deceased for several hours prior to their arrival, despite staff statements regarding the last time the resident was seen alive. Facility policy required immediate initiation of CPR for residents with full code status, but this was not followed. The incident affected one resident directly, with the facility identifying 178 residents with full code status at the time of the survey.
Failure to Ensure Code Status Orders Match Advance Directives
Penalty
Summary
The facility failed to ensure that a resident's code status orders accurately reflected their wishes as documented in their Advance Directives Form. Specifically, a cognitively intact resident with multiple complex medical diagnoses, including chronic kidney disease, heart disease, and diabetes, had a signed Advance Directives Form indicating a preference for Do Not Resuscitate Comfort Care-Arrest (DNR CC-A). Despite this, the physician order in the medical record listed the resident as full code from the time of admission until two months later, at which point the order was changed to DNR CC-A. This discrepancy was confirmed through medical record review and interview with the Director of Nursing, who acknowledged that the resident's code status order did not match the documented advance directive for a significant period. The facility's policy requires that advance directives be respected and that the plan of care be consistent with the resident's documented treatment preferences, but this was not followed in this case.
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