Failure to Document Advanced Directives Leads to Critical Incident
Summary
The facility failed to formulate and document Advanced Directives for five out of six residents reviewed, leading to a critical incident involving a resident who was found unresponsive. The resident, who had no documented Advanced Directives, was not provided CPR by the staff, despite the absence of a Do Not Resuscitate (DNR) order. The resident's family later confirmed that the resident had expressed a desire to be resuscitated, which was not honored due to the lack of documentation. The facility's policies require that upon admission, residents are informed of their rights to accept or refuse medical treatment and to formulate an advance directive. However, this process was not completed for several residents, including the one who passed away without receiving CPR. The staff involved were unaware of the resident's code status due to incomplete documentation, resulting in a failure to initiate life-saving measures. Interviews with staff revealed a lack of understanding and communication regarding the responsibility for documenting and acting upon Advanced Directives. The admitting nurse did not complete the necessary documentation, and the nurse who found the resident unresponsive did not perform CPR, citing the absence of Advanced Directives in the resident's chart. This oversight led to an Immediate Jeopardy situation, highlighting significant gaps in the facility's adherence to its own policies and procedures.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with multiple cardiopulmonary conditions and a documented full code status was found unresponsive without pulse or respirations during the night shift. A CNA notified the RN, who either instructed CNAs to clean and cover the resident or, per her and an LPN’s account, called a code blue and performed CPR with the LPN for about 20 minutes before stopping, without calling 911. The RN believed the resident was on hospice and did not verify code status, then notified the DON, provider, and family instead of EMS. Several hours later, after the DON called the facility and asked whether 911 had been contacted, the RN called 911 and briefly reinitiated CPR shortly before EMS arrived and pronounced the resident deceased, documenting postmortem changes. The facility’s investigation and root cause analysis found that staff failed to follow policy requiring immediate EMS activation and continuous CPR for full code residents until EMS arrival, leading to an Immediate Jeopardy finding.
A resident with multiple chronic conditions and severe cognitive impairment was found unresponsive and not breathing, with no documented code status, POLST, or DNR in the medical record. Nursing staff verified the absence of respirations and pulse but did not initiate CPR or call 911. An LPN reported she proposed starting CPR due to the unknown code status, but an RN declined. Leadership and clinical staff stated in interviews that facility practice and expectations are that, when a code status is unknown or no POLST is on file, the resident is to be treated as full code and CPR should be initiated.
The facility failed to maintain accurate and complete crash cart audits for multiple full-code residents. Surveyors, accompanied by the DON, found that daily crash cart checks did not include verification of supply expiration dates, and that an extension cord documented as present on several audit dates was not actually in the cart. Audit logs also conflicted with the cart’s contents by indicating that required items such as eye protection, saline, and clear plastic were present when they were not. These findings were inconsistent with the facility’s policy requiring the crash cart to be checked every 24 hours and after each use, with prompt replacement of equipment and supplies.
A resident with NASH, diabetes, ascites, obesity, and a documented Full Code status was found unresponsive during early morning med pass, cool to the touch and without measurable vital signs. Her care plan and orders required staff to call 911 and start CPR and life-saving measures if she had no pulse or respirations, but the LPN and RN who assessed her did not initiate CPR, did not contact EMS, and did not verify her code status in the medical record at the time. The resident had not been checked for several hours overnight despite policies requiring at least q2h rounding for changes in condition. There was no documentation that she had been deceased for an extended period, no report of rigor mortis, and no evidence of any change in condition prior to being found unresponsive, resulting in a cited deficiency for failure to follow code status and emergency response policies.
A resident with documented dementia, depression, coronary artery disease, and a clearly established DNR/DNI status on the care plan, orders, and MOLST was found unresponsive in the bathroom without pulse or respirations. An LPN, notified by a CNA, initiated CPR without checking the resident’s code status in the paper chart or EMR. When the RN supervisor arrived and asked about code status, the LPN incorrectly reported the resident as full code, and another RN assisted with chest compressions without verifying code status. Staff experienced confusion and delay locating the MOLST and paper chart, and EMS requested confirmation of the resident’s code status. The MOLST ultimately confirmed DNR/DNI, but CPR had already been performed until EMS consulted their provider and stopped the code, after which the resident was pronounced deceased.
A resident with multiple cardiac and renal conditions and a documented Full Code status was found unresponsive and not breathing by a transportation aide, who immediately sought help from an LPN and the assigned RN. The LPN refused to assist, stating it was not their resident, and the RN twice delayed responding despite being told it was an emergency, leading to a reported five- to ten-minute delay before any nurse entered the room. An LPN from another unit eventually initiated chest compressions, and other nurses joined, but no artificial respirations were provided at any time, even though the resident was apneic and an Ambu bag was available. This response did not follow the facility’s CPR policy or AHA guidelines for trained healthcare providers, which require full BLS with both compressions and rescue breaths for a Full Code resident prior to EMS arrival, and the situation was cited as Immediate Jeopardy with actual serious harm and subsequent death.
Failure to Provide Required CPR and Activate EMS for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide immediate and appropriate basic life support, including CPR, to a resident with a documented full code status when the resident was found unresponsive. The resident had diagnoses including a slow-progressing circulatory condition involving narrowing or blockage of vessels, a condition that restricts airflow and makes breathing difficult, and other listed conditions. The physician’s order specified “Full Code,” and the care plan documented that the resident was under court-ordered guardianship with wishes honored as full code. The facility’s policy required that in the event of cardiac or respiratory arrest, staff immediately call for assistance, overhead page a code, begin CPR in the absence of a valid DNR, and continue CPR until EMS assumes responsibility or the resident responds. On the night of the incident at approximately 2:00–2:07 a.m., a CNA found the resident unresponsive in bed and notified the RN on duty. One CNA’s written statement indicated that the RN said she already knew the resident was going to die and instructed the CNA to clean and cover the resident. Another CNA’s account stated that the RN came to the room, took vital signs, and then instructed her to clean the resident. The RN’s own written statement and interview indicated that she called a code blue, that an LPN brought the crash cart, and that they performed CPR for approximately 20 minutes. The LPN’s statement corroborated that a code blue was called, that he brought the crash cart, and that CPR was performed for about 20 minutes before the RN stopped and stated that the resident was gone or words to that effect. The RN acknowledged that the resident had no vital signs but was warm and not responding, and she stated that she believed the resident was on hospice and therefore did not call 911. After CPR was discontinued, the RN did not activate EMS and instead notified the DON, the provider, and the resident’s family. The DON documented receiving a message from the RN that the resident had no pulse and no blood pressure and that the assigned nurse had initiated CPR but was unable to revive the resident. The DON later received a text from the RN that the resident had expired. The DON stated that at approximately 6:00 a.m. she called the facility and asked if 911 had been called, and upon learning it had not, she instructed the RN to call 911. The RN then reinitiated CPR at around 6:00 a.m., approximately four hours after the resident was first found without pulse or respirations, and stated that they tried to do something until EMS arrived because EMS had to see them doing CPR. EMS records showed activation at 6:18 a.m., arrival at 6:27 a.m., and pronouncement of death at 6:31 a.m., with documentation that CPR was not attempted by EMS because it was considered futile and that the resident exhibited postmortem changes. The Medical Director confirmed that the resident was full code and stated that staff should have started CPR and called 911 and that CPR should not be done four hours after a resident is pronounced dead. The facility’s investigation and a root cause analysis concluded that the RN and LPN did not follow the facility’s established policy and procedure to call 911 and administer CPR to a full code resident until EMS arrival. The root cause was identified as the nurse’s belief that the resident was on hospice and her failure to check the resident’s code status as outlined in facility policy. The surveyors determined that the failure to immediately activate EMS and to continue CPR until EMS arrival for this full code resident constituted noncompliance with the requirement to provide basic life support and resulted in an Immediate Jeopardy determination.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied. Resident #1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All codes to 1.1.26 were reviewed to ensure protocol was followed. No outliers were noted. All licensed nurses received education from the Director of Nursing and/or nursing management on [R] policy and procedure and Florida [R] policy. This includes where to find the code status. Education addressed what to do for full code hospice residents. Education completed with CNA's that protocol is that they do not assist with [R] or breaths during a [R] event. All education will be added to new hire orientation. Code drills will occur 3 x weekly x 4 weeks, followed by 2 x weekly x 4 weeks, followed by 1 x weekly x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Educated licensed nurses on CPR policy and procedure and Florida Do Not Resuscitate (DNRO) policy, including where to find code status and what to do for full code hospice residents; emphasized initiating emergency services immediately when resident is full code, continuing CPR until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS.
- Implemented emergency response “Code Blue” drills on all three shifts, including full code and full code hospice scenarios, with emphasis on calling 911 immediately.
- Educated licensed nurses and CNAs on the facility abuse and neglect policy, including resident rights.
- Required licensed nurses to complete a CPR post-test; restricted staff who have not completed education/testing from working until completion.
- Educated licensed nurses regarding change in condition.
- Placed laminated instructions on how to overhead page during a code at all nursing station phones and other designated phones.
- Held a Quality Improvement Performance Committee meeting to review root cause analysis findings and approve recommendations.
- Held a Quality Improvement Performance Committee meeting to review progress of the plan and approve recommendations.
- Completed a “like resident” audit of all expired residents and rehospitalizations for a defined period to determine whether involved staff were the same as the code event and whether proper procedure was followed.
Failure to Initiate CPR for Resident With Unknown Code Status
Penalty
Summary
The deficiency involves the facility’s failure to initiate cardiopulmonary resuscitation (CPR) and call emergency medical services for an unresponsive resident whose code status was unknown. The resident had been admitted with diagnoses including chronic obstructive pulmonary disease, cirrhosis of the liver, hypertension, and dysphagia, and was documented as severely cognitively impaired and dependent on staff for several activities of daily living. The resident’s medical record did not contain any documentation of a code status, POLST, DNR order, or other advance directive limiting resuscitative efforts. In the early morning hours, a nurse entered the resident’s room to assist the roommate and observed that the resident was not breathing but was still warm to the touch. The nurse then obtained a second nurse to verify the absence of breathing. The facility’s final investigation report states that the nurse assessed the resident and noted absence of respirations, absence of a palpable pulse, and physical findings consistent with post-mortem changes, and determined the resident had expired. Despite the lack of any documented DNR or advance directive in the record available for review at that time, CPR was not initiated and 911 was not called. Interviews with staff confirmed that the resident’s code status was unknown at the time of the event and that no resuscitative efforts were made. The ADON stated that if a resident’s code status or POLST form cannot be found, the resident is considered a full code, and that when in doubt a resident is a full code. The DON reported that the LPN who found the resident did not know the code status and did not initiate CPR or call 911, even though the resident was a recent admission and no POLST form was on file. The LPN stated she suggested initiating CPR because there was no POLST, but the RN present told her not to start CPR. Other staff interviewed stated that if a resident’s code status is not known or cannot be found, CPR is supposed to be initiated.
Inaccurate Crash Cart Audits and Missing Emergency Equipment
Penalty
Summary
The facility failed to ensure accurate and complete crash cart audits for residents requiring basic life support, affecting eighteen of thirty-five residents who were designated as full code. During an observation of the crash cart with the DON, surveyors found that the daily audit documentation for the month did not include verification of expiration dates for crash cart supplies. Review of the crash cart audit logs showed that an extension cord was documented as being in the cart on multiple dates, but the extension cord was not present in the cart at the time of inspection. Additionally, the audit documentation indicated that required items, including eye protection, saline, and clear plastic, were not present in the crash cart, yet they were documented as being in the cart. The facility’s undated “Emergency Crash Cart” policy stated that the crash cart is to be checked every 24 hours and after every use, and that equipment and supplies are to be noted and replaced promptly, but the observed documentation and contents of the cart did not match these requirements. This deficiency was verified with the DON at the time of the survey and was cited under the requirement that personnel provide basic life support, including CPR, to residents requiring emergency care, subject to physician orders and advance directives, and was investigated under Complaint Number 2687380.
Plan Of Correction
Cridersville Care Center Provider Number:366171 Survey Type: Complaint Survey Survey Date: 04/29/26 This Plan of Correction (PoC) outlines the actions completed by the facility with regards to the deficiency citation. This Plan of correction does not constitute any admission of guilt or liability by the facility and is submitted only in response to the regulatory requirements. Please accept the following as the facility's credible allegation of compliance as of 4/30/26. F678 CPR All Full Code residents #18 have the potential to be affected by the alleged deficiency. On 4/27/26 the DON/ADON re-stocked the crash cart per the inventory sheet for all missing items. Crash cart inventory sheet updated and new one will go into effect on 5/1/26. All licensed nursing staff provided with training related to crash cart inventory being a daily audit review using inventory sheet on 4/27/26 per DON/designee. The DON/designee will conduct clinical rounds and conduct a random audit of crash cart three times per week for 4 (four) weeks to ensure compliance. The results of the audit will be documented. The facility conducted an Ad-Hoc QAPI meeting on 4/27/26 and discussed the alleged deficiency and corrective actions. Date when corrective action will be completed: 4/30/26
Failure to Initiate CPR and Contact EMS for Full Code Resident Found Unresponsive
Penalty
Summary
The deficiency involves the facility’s failure to initiate CPR or contact EMS for a resident who had an advance directive for Full Code when she was found unresponsive without vital signs. The resident had been admitted with diagnoses including nonalcoholic steatohepatitis (NASH), diabetes, ascites, and obesity, and was documented as cognitively intact. Her care plan and physician orders specified a Full Code status with interventions to call 911 if her heart stopped, start CPR if she was not breathing or had no pulse, and initiate oxygen or life-saving breaths via an ambu bag if she stopped breathing. The plan of care also directed staff to keep a copy of her resuscitation wishes in the medical record and to notify the physician and family if she stopped breathing or her heart stopped. On the date of the incident at approximately 5:30 A.M., during morning medication pass, an LPN found the resident nonresponsive, cool to the touch, and unable to obtain blood pressure, pulse, or respirations. A second nurse, an RN, verified there was no heartbeat or breath sounds. Despite these findings and the resident’s Full Code status, no CPR was initiated and EMS was not contacted. The progress notes documented that the resident had expired, but there was no documentation of any change in condition prior to her death, no indication that CPR was started, and no evidence that EMS was called. The record also did not document that the resident had been deceased for an extended period of time, and the DON later confirmed that no staff had reported signs of rigor mortis when the resident was found. Interviews revealed additional context regarding monitoring and staff actions prior to the resident being found unresponsive. A CNA reported that the agency CNA assigned to the resident had been difficult to locate and was often sitting at the desk, and that she learned of the resident being found unresponsive when the LPN was trying to find the RN to confirm the lack of vital signs. The DON stated that the agency CNA was the resident’s assigned CNA and acknowledged that staff did not check on the resident timely, making it unknown how long she had been unresponsive before 5:30 A.M. The DON confirmed that staff should have performed CPR and called 911 for this Full Code resident and that the resident’s body was sent directly from the facility to the funeral home. The agency CNA later stated he last checked the resident between midnight and 1:00 A.M., when she appeared to be sleeping, and did not check on her again before she was found unresponsive at 5:30 A.M. Further interviews with nursing staff highlighted failures to verify and act on the resident’s code status at the time of the event. The RN who assisted with the assessment stated she had never previously cared for the resident and that the LPN told her the resident was unresponsive and that she was unsure of the code status and could not find it. The RN confirmed she did not verify the code status in the medical record, did not initiate CPR, and did not call 911, and she could not explain why these actions were not taken. She reported that she briefly assessed the resident using a stethoscope without moving or touching her beyond that, noted the resident appeared grayish, and quickly left the room to continue medication pass. The DON confirmed that, per facility policy, in the absence of a signed DNR document a resident is to be considered Full Code, that resuscitation attempts must be started immediately upon noting absence of vital signs regardless of body temperature or lividity, and that staff must promptly call 911, the provider, and the emergency contact. These required actions were not carried out in this case, leading to the cited deficiency. The facility’s own policies on code status and change in condition further underscored the expectations that were not met. The policy directed staff to check the active order profile and point-of-care dashboard for code status, to treat any resident without a signed DNR as Full Code, and to initiate resuscitation immediately upon absence of vital signs. It also required staff to round at least every two hours to check for changes in condition and to promptly report and assess any abnormal findings. In this incident, staff did not adhere to these policies: the resident was not monitored at least every two hours during the night, her Full Code status was not verified at the time she was found unresponsive, CPR was not initiated, and 911 was not called, despite the absence of vital signs and the lack of documented evidence that she had been deceased for an extended period.
Failure to Verify and Honor DNR Status Before Initiating CPR
Penalty
Summary
The deficiency involves the failure of nursing staff to verify and follow a resident’s documented Do Not Resuscitate (DNR) status and advance directives before initiating cardiopulmonary resuscitation (CPR). Facility policy on Basic Life Support required that CPR, rescue breathing, and defibrillation be initiated on all appropriate residents unless advance directives excluding these procedures were on file in the medical record. The resident involved had documented advance directives, including a health care proxy and an activated Medical Orders for Life Sustaining Treatment (MOLST) form specifying DNR and Do Not Intubate (DNI) status. Multiple records, including the care plan, order listing report, MOLST, and a provider note, consistently documented that the resident’s code status was DNR/DNI and that natural death should be allowed. On the day of the incident, the resident, who had diagnoses including dementia, depression, and coronary artery disease and was assessed as usually understood, usually understands, and moderately cognitively impaired, was found unresponsive in a folding chair in the bathroom. A certified nurse aide notified an LPN that the resident was unresponsive. The LPN went to the room, found the resident unresponsive and without a pulse or respirations, and paged the nursing supervisor STAT. The LPN then returned to the resident, confirmed there was no pulse, lowered the resident to the floor, and initiated chest compressions without checking the resident’s code status in either the paper chart or the electronic medical record, despite knowing that code status could be found on the MOLST form at the nurse’s station or under the resident’s picture in the electronic record. As the code progressed, additional nursing staff responded. The nursing supervisor entered the room while the LPN was performing CPR and asked about the resident’s code status. The LPN stated the resident was a full code, and the supervisor assumed the code status had been checked. Another RN assisted with chest compressions and also did not ask or verify the resident’s code status before participating in CPR. There was confusion when EMS arrived and requested the resident’s code status and MOLST form. An RN unfamiliar with the unit and experiencing issues with the nurse’s station computers had difficulty locating the paper chart, which delayed confirmation of the resident’s DNR/DNI status. Once the MOLST was found and reviewed, it showed the resident had DNR/DNI orders, but CPR had already been initiated and continued until EMS contacted their provider and terminated the code. The resident expired at the facility.
Failure to Provide Timely and Complete CPR to a Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to promptly and correctly provide basic life support (BLS), including CPR, to a resident with a documented Full Code status who was found unresponsive and without vital signs. The resident had multiple significant diagnoses, including atrial fibrillation, type 2 diabetes, congestive heart failure, end-stage renal disease, anxiety, dementia, kidney cancer, anal fistula, hypertension, and dependence on hemodialysis. The resident’s care plan identified risk for ineffective breathing related to CHF and ESRD, with interventions such as monitoring breath sounds, labored breathing, use of accessory muscles, oxygen therapy as needed, vital signs as needed, cardiac medications, and lab monitoring. On the morning of the event, the resident had last been known responsive when a CNA delivered breakfast and the resident verbally acknowledged the tray. At approximately the time the resident was to be prepared for dialysis, a transportation aide entered the room and found the resident in distress, noting a deep breath followed by absence of respiratory effort and no response to verbal or tactile stimulation. The aide immediately sought help from an LPN, who refused to assist, stating, "that's not my resident," and did not assess or enter the room. The aide then approached the RN assigned to the resident, who twice responded, "I'll get to it when I can," despite the aide stating that the situation could not wait and that the resident was in distress. During this period, the aide reported waiting outside the resident’s room for approximately five to ten minutes before any nurse came to help, and ultimately used the overhead paging system to summon assistance because no nurse initially responded to her direct requests. An LPN from another unit responded to the overhead page, entered the room, and found the resident absent of vital signs, initiating chest compressions and calling for help. Other staff, including the assigned RN and another LPN, then entered and assisted with compressions and obtaining equipment such as the crash cart and AED. However, multiple staff interviews and the assigned RN’s own verification confirmed that no artificial respirations were provided at any time, despite the resident not breathing and an Ambu bag being available on the crash cart. The facility’s CPR policy required adherence to current AHA guidelines, which for trained healthcare providers include cycles of 30 chest compressions to two rescue breaths, and the policy required provision of BLS, including CPR, prior to EMS arrival in accordance with the resident’s advance directives. EMS arrived to find staff performing CPR, determined the resident was pulseless and apneic, and continued advanced resuscitation efforts. The failure to respond promptly to the aide’s report of an emergency, the refusal of one nurse to assist, the delay by the assigned RN in assessing the resident, and the omission of rescue breaths during CPR for a Full Code resident constituted the basis of the cited deficiency and were determined to have resulted in Immediate Jeopardy and actual serious life-threatening harm and subsequent death.
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