A resident with CHF was found unresponsive and CPR was performed even though the chart contained an active DNR order, an MDS indicating DNR, and a POLST choosing DNR and allowing natural death. LN stated she reviewed the physician order at the time and confirmed the resident was DNR, and the DON confirmed the resident's orders and POLST indicated DNR.
A resident with full code status was found unresponsive with critically low O2 saturation, then pulseless and not breathing. The assigned LPN called 911 but did not give oxygen or start CPR, left to find help and retrieve a crash cart, and the resident remained in a wheelchair until EMS arrived. The DON and ADM confirmed no life-saving measures were initiated before the resident was pronounced dead.
Delayed CPR and 911 Activation for an Unresponsive Resident: A resident with a trach, ventilator dependence, severe cognitive impairment, and a POLST requiring CPR was found discolored, unresponsive, pulseless, and without an O2 sat reading. RT staff and an LPN checked multiple pulse sites and retrieved equipment before CPR began, and 911 was not called until several minutes after the resident was found. Paramedics arrived later and took over resuscitation.
RN 2 did not maintain CPR/BLS certification from a provider that included the required hands-on skills component. File review showed the certification came from an online provider, and RN 2 stated the course was entirely online with reading, videos, and questions only, with no CPR skills demonstration. The DSD confirmed the certification needed hands-on validation under the facility CPR policy.
A resident with a full code status and diagnoses including a-fib, arteriosclerosis of the aorta, and cardiomegaly was found unresponsive in his room. CNA 1 and CNA 2 shook him but did not immediately check for breathing or a pulse, activate 911, or start CPR. Staff response was delayed until an LPN and others arrived, and EMS later found the resident pulseless and apneic; he was pronounced dead by paramedics.
A resident with COPD, HF, pulmonary HTN, and a POLST requiring CPR was found unresponsive, apneic, and pulseless after a fall and monitoring period. RN and CNA staff who were CPR certified did not immediately start CPR, and several CPR-certified nurses and CNAs were present during the code blue but did not assist until another nurse began compressions. The facility also lacked a designated CPR team and team leader for the shift, despite its policy requiring one and directing staff to follow AHA BLS guidance.
CPR Certification Lacked Required Hands-On Training: The facility failed to ensure an LVN maintained a current CPR certification from a provider that included hands-on practice and skills assessment. The LVN stated her CPR course was completed online with videos and a test and did not include an in-person hands-on component. The DON stated CPR training should include hands-on practice, and the facility policy required CPR certification through a provider meeting accepted national standards.
Failure to Provide Rescue Breaths During CPR: A resident with MI and CVA history was found unresponsive with absent respirations and no palpable pulse. Staff initiated chest compressions, but rescue breaths were not given at the start of CPR because an Ambu bag or CPR shield was not available to the LPNs/CNA, and an RN later had to leave the room to get an Ambu bag. The DON stated CPR required 30 compressions and 2 breaths, and the facility policy required ventilations via Ambu bag or CPR shield.
Expired BLS/CPR Certifications for DON and CNA: The facility failed to ensure that the DON and a CNA maintained current BLS/CPR certification. During record review and interviews, the DSD stated the DON’s BLS/CPR had expired and that CNA 10’s BLS/CPR had also expired without renewal. Facility policy required CPR-certified staff to be available at all times and direct care staff to recertify annually, and the DON and CNA job descriptions both required current BLS/CPR certification.
A full-code resident with multiple medical conditions and a POLST requiring CPR was found unresponsive, not breathing, and pulseless by a CPR-certified CNA, who left the resident to seek help instead of activating a Code Blue, calling 911, and starting CPR. An LVN and RN later arrived with a crash cart but delayed CPR while attempting to obtain blood pressure, using a pulse oximeter, performing a sternal rub, and checking the resident’s eyes before confirming pulselessness and beginning chest compressions and rescue breathing. 911 was not called until several minutes after the initial discovery of unresponsiveness, and paramedics subsequently provided advanced resuscitation efforts before the resident was pronounced dead, leading surveyors to cite the facility for failing to follow its CPR policy and AHA BLS guidelines.
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