Nursing Home Fails to Provide CPR for Resident

Countrywood Nursing Center was cited after failing to provide a resident with Cardiopulmonary Resuscitation (CPR). The resident was a “full code status,” meaning he was to receive CPR if found unresponsive. When a staff member found the resident cold and not moving in bed, CPR was not given as ordered. The resident ultimately passed away.

The investigator of this citation reviewed nursing notes and conducted interviews to determine why CPR was not provided. According to a note, the resident had a “decline in status and had removed his [medical condition] mask.” The note said the resident continued to remove his mask and try to get out of bed on his own. When a nurse entered the room and found the resident’s mask on the floor, she noted he was cold to the touch when trying to reapply the mask.

The interviewer spoke with the Licensed Practical Nurse (LPN) who found the resident unresponsive. She stated the following:

I went into [the resident’s] room and noted the [medical condition] mask to be on the floor, I picked it up to replace it and when I touched the resident’s arm, it fell to the floor. I remembered the resident was a full code, so I proceeded to walk down the hall to the utility room, grabbed the crash cart, went behind the nurses’ desk and grabbed my stethoscope, checked the resident’s medical record to verify the code status and then I called the Registered Nurse (RN) on call to verify what to do. Upon talking to the RN, I was told not to perform CPR because at this point I would be doing more harm than good.

The interviewer asked the LPN if she was aware of the facility’s CPR policy. The LPN stated no. An interview with the Director of Nursing (DON) confirmed there “was no reprimand neither was re-education provided” to the LPN after the incident.

Review of the facility’s Emergency Procedure-Cardiopulmonary Resuscitation revealed the following:

If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS (Basic Life Support) shall initiate CPR unless;

– It is known that a Do Not Resuscitate (DNR) order specifically prohibits CPR and/or external defibrillation exists for that individual; or
– There are obvious signs of irreversible death (e.g., rigor mortis).

In response to the incident, the facility immediately provided CPR education for the nursing staff present. The Social Service Director completed a chart review of all current residents, noting at-risk residents with a full code status. All licensed and registered staff off duty were contacted via phone and required to attend a facility-wide meeting. All staff received a mandatory training to review Policy and Procedure on CPR and review identified at-risk residents with full code status. In addition, staff members were instructed to notify the DON when at-risk residents had a significant change in condition and/or when emergency procedures were initiated.

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