CPR was started on a resident with a documented DNR order after the resident was found unresponsive in the dining room. The resident had COPD, CHF, and diabetes, and the DNR was listed in the care plan, physician orders, and an outside hospital DNR form, though the face sheet did not show code status. Staff later verified the DNR and stopped CPR, and interviews showed mixed understanding about whether CPR should begin before code status is confirmed.
Failure to provide timely CPR and EMS activation for a resident with conflicting code status documentation. A resident admitted for respite care with Hospice services was documented as Full Code in the chart, while other records referenced DNR status. When the resident was found unresponsive, staff were confused about the code status, CPR was delayed, and there was disagreement among the DON and LPNs about whether a signed DNR was present before life-saving measures were started.
Inconsistent code status documentation was found for two residents. One resident had DNR orders in the EMR and POS, but the room sticker, care plan, and physical chart binder showed full code, while staff knew the status had changed but did not know when or why all areas were not updated. Another resident had DNR orders and a DNR care plan, but the DNR paperwork was missing from the binder and the binder spine was labeled full code; an LPN said CPR would be started because there was no DNR indicator. Staff interviews showed confusion about where code status should be documented and who was responsible for keeping the EMR, paper chart, and room indicators consistent.
Inconsistent code status documentation: Two residents had conflicting records showing both DNR and full code across the chart, care plan, and door identifiers. One resident had a living will and DNR documents, yet the POS listed full code; another resident's face sheet and OHDNR showed DNR, but the POS listed full code. Staff interviews confirmed that code status should match throughout the record, but the documentation was not consistent.
Inconsistent Code Status Documentation: The facility failed to keep code status consistent across records for two residents. Both residents had DNR documented in the electronic record, current POS, and care plan, but the face sheet binder at the nurses' station listed them as full code, and staff gave inconsistent answers about where to find code status. The DON stated there was no system in place for code status audits, while the Administrator said audits were done bi-monthly.
A resident with cardiac and pulmonary conditions, initially defaulted to full code status, later completed a physician-signed DNR order that was placed in an admission folder but not communicated to nursing or entered into the EMR. The Admissions Director did not forward the DNR paperwork to the SSD or DON, and the SSD created the resident’s profile as full code, leaving the hard chart, EMR, and door sticker system all reflecting full code. When the resident was found unresponsive, staff and EMS initiated and continued CPR based on the incorrect full code information, and only afterward did the SSD discover the signed DNR form in the admission packet.
Failure to Initiate CPR for a Full Code Resident: A resident with cardiac and respiratory diagnoses was documented as Full Code and had a TPOPP/POLST requesting CPR if found without a pulse and not breathing. After the resident was found unresponsive, not breathing, and without a pulse, an LPN asked a family member whether CPR should be started and waited several minutes while the family member decided; CPR was not performed and the resident died at the facility. Interviews showed the LPN knew the resident was Full Code but did not initiate CPR, and staff stated CPR should have been started regardless of the family member’s statement.
A resident with schizophrenia, bipolar disorder, HTN, and type 2 DM was admitted with conflicting code status documentation: one page of the face sheet and the emergency book listed DNR, while another page of the face sheet, the physician’s orders, and a signed health care directive defaulted the resident to full code (CPR). One morning, a CNA found the resident unresponsive across the bed and summoned an RN, who noted no pulse, no respirations, and cyanosis but did not initiate CPR, relying on the DNR status shown in the emergency materials. Interviews with CNAs, LPNs, the MDS coordinator, SSD, DON, NP, Medical Director, and Administrator confirmed that, in the absence of a signed DNR or when documentation conflicted, the resident should have been treated as full code and CPR started, but this did not occur, leading to the cited deficiency.
Staff failed to honor a full-code resident’s wishes for CPR when an LPN discontinued resuscitation efforts before EMS arrived. The resident, who had COPD, prior intracerebral hemorrhage, and kidney cancer, was documented as full code on the face sheet, care plan, and physician orders. When the resident was found unresponsive with fluid from the nose and mouth and no pulse, the LPN verified full-code status, directed staff to call 911, and began chest compressions. As fluid and vomit were observed, the LPN rolled the resident to the side, then stopped CPR, stating the resident had aspirated and could not be resuscitated, and did not proceed with suction. Other staff and later-arriving EMS and the coroner confirmed that CPR had been stopped prior to EMS arrival, despite facility expectations that CPR for a full-code resident be continued until EMS assumes care.
A resident experienced a delay of up to nine minutes in receiving rescue breaths and oxygen during CPR because the Ambu bag mask was missing from the crash cart and staff were unable to operate the suction machine. Chest compressions were started promptly, but rescue breaths and suctioning were delayed due to missing supplies and lack of staff knowledge. When EMS arrived, staff stopped CPR before EMS was ready to take over, resulting in a lapse in compressions. The resident, who had severe cognitive impairment and multiple medical conditions, expired as a result.
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