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.
A resident with significant cardiac history and a POLST indicating full code status became weak, developed shallow breathing, stopped talking, and became unresponsive after dinner. CNAs summoned nursing staff, but the RN focused on obtaining vital signs and verifying code status, left the resident sitting upright, and did not initiate CPR, citing a pain response as evidence of responsiveness. An LVN recognized abnormal breathing and the need to call 911 but did not start CPR, and another LVN was unaware that ventilation should be provided to an unresponsive resident with slow breathing; no staff performed chest compressions before EMS arrival. The crash cart contained only 8 L/min oxygen regulators, preventing proper BVM use at 15 L/min, and the RN could not determine that the oxygen tank was empty or correctly connect the suction machine. EMS arrived to find the resident pulseless, apneic, in asystole, and with no CPR in progress, leading surveyors to cite a deficiency for failure to provide immediate, effective BLS and CPR to a full-code resident.
A resident with intellectual developmental disability and severe cognitive deficits was allowed to remain unsupervised in a wheelchair in a hallway, despite some staff being aware the resident was a fall risk and observing attempts to stand. After the resident was found on the floor with a bleeding head wound, minimally or non-responsive and exhibiting agonal or irregular breathing but with a pulse, nursing staff applied oxygen via a non-rebreather mask but did not assess chest rise, did not provide rescue breaths, and inaccurately documented chest compressions as performed. Leadership later confirmed that staff were expected to follow AHA BLS guidelines, which require rescue breathing for an unresponsive person with a pulse and abnormal or ineffective breathing, and that passive oxygen alone does not ensure ventilation.
Surveyors found that one of two licensed nurses did not have CPR certification that included required hands-on skills training. The nurse, employed through an agency, obtained CPR certification from an online provider that offered only written testing without in-person or virtual instructor-led skills validation. The Administrator reported that all licensed nurses, including agency staff, were expected to maintain CPR for Healthcare Providers with hands-on practice on a mannequin. Facility policy required CPR training with a hands-on component in line with AHA guidelines, but this was not met for the nurse, decreasing the facility’s potential to provide effective basic life support and CPR for all residents during respiratory or cardiac emergencies.
A resident with severe cognitive impairment, dysphagia, and a full-code status was given a cookie by a visitor despite being on a pureed diet. Shortly afterward, the resident was found pale, unresponsive, not moving, and with food in the mouth. A CNA, an RNA, and an LVN responded but did not assess responsiveness, did not check for a pulse or breathing, and did not initiate CPR as required by facility policy and CPR guidelines. Instead, they focused on performing the Heimlich maneuver and moving the resident between the bed and a chair. CPR was only started after an RT arrived, found no pulse, and directed staff to return the resident to bed and begin resuscitation, resulting in a delay in basic life support for a full-code resident.
A resident with a full code status did not receive immediate or effective BLS/CPR when found unresponsive, as staff delayed initiating CPR while searching for code status, failed to use a backboard or Ambu-bag, and performed inconsistent chest compressions. Some staff lacked current BLS/CPR certification, and the emergency cart was not properly stocked, resulting in inadequate life-saving measures.
A resident capable of making her own decisions did not have a valid POLST on file, as it was signed by a family member acting only as an interpreter. During a medical emergency, staff were unable to promptly determine the resident's code status and delayed CPR while consulting with family members, despite the presence of a DNR order signed by an unauthorized individual. Paramedics performed CPR upon arrival, but the resident expired.
A resident with multiple serious diagnoses and a documented Full Code status was found unresponsive and without vital signs. Despite clear documentation and the representative's wishes for full resuscitation, licensed staff did not initiate CPR or call a Code Blue, and no life-saving measures were attempted prior to hospice arrival. Staff interviews confirmed a lack of protocol adherence and understanding, and the facility's policy requiring basic life support in the absence of a DNR order was not followed.
A resident with a full-code POLST was found unresponsive and pulseless in a wheelchair on the patio. Instead of starting CPR immediately as required by AHA guidelines and facility policy, staff moved the resident to his room before initiating resuscitation. Multiple staff and a physician confirmed that CPR was not started at the scene, resulting in a delay before emergency measures began. Paramedics later pronounced the resident dead after unsuccessful resuscitation.
A CNA was found to lack a CPR certification accredited by the ARC or AHA, contrary to facility policy requiring all CPR team members to hold such credentials. This was confirmed through interviews and record review with the DON and DSD, who acknowledged the oversight during the hiring process and the importance of compliance with the facility's emergency procedures.
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