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.
A resident's code status was not clearly documented or accessible in required locations, leading to a delay when staff could not quickly determine the appropriate emergency response during a medical event. Staff interviews revealed that code status information was inconsistent and not updated due to a vacancy in the Social Services Director position, resulting in confusion and delayed initiation of CPR.
A resident with a physician's order for Do Not Resuscitate (DNR) was found unresponsive and without a pulse. The charge nurse initiated a Code Blue and started CPR without first confirming the resident's code status in the electronic medical record. EMS arrived and continued resuscitation efforts, only learning of the DNR order after arrival. Despite advanced interventions, the resident remained in asystole and resuscitation was eventually discontinued.
A resident with a signed DNR order did not have their code status consistently documented across the EMR, face sheet, and door sticker. Due to delays in updating records, staff initiated CPR when the resident became unresponsive, as available documentation indicated full code status. Staff interviews confirmed that delays and inconsistencies in updating advance directives contributed to the failure to honor the resident's wishes.
A resident with a signed DNR order did not have their code status accurately updated in the physician orders or medical record banner. When the resident was found unresponsive, staff could not verify the DNR status and performed CPR, with EMS continuing life-saving measures. The failure to update and communicate the resident's code status led to the deficiency.
A resident was found unresponsive and staff initiated CPR and called EMS, despite the hospice record indicating a DNR order and documented consent for no resuscitation. Facility records showed conflicting code status orders, and staff interviews revealed incomplete documentation, lack of verification, and confusion regarding the resident’s wishes. The inconsistent system for documenting and communicating code status led to the initiation of CPR against the resident’s documented DNR preference.
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