§483.24(a)(3) Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives.
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Observations:
Based on review of guidelines for Cardiopulmonary Resuscitation (CPR), facility's policies, staff interviews and residents' clinical and hospital records, it was determined the facility failed to ensure that code status was documented on the residents clinical record delaying the decision to provide life sustaining measures such as CPR for one of five residents reviewed (Resident CL1), creating a situation in which the residents were placed in Immediate Jeopardy related to failure to perform life sustaining interventions.
Findings include:
Review of the American Health Association (AHA) Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, published on November 2, 20210, revealed the AHA recommends all potential rescuers to initiate CPR unless a valid, Do Not Resuscitate (DNR) order was in place; if there were obvious clinical signs of irreversible death present, including rigor mortis (stiffness of the limbs and body that develops 2 to 4 hours after death and may take up to 12 hours to fully develop), dependent lividity (reddish-blue discoloration of the skin resulting from the gravitational pooling of blood in the lower lying parts of the body in the position of death), decapitation (separation of the head from the body), transection (division by cutting across the body), or decomposition (decay); or if initiating CPR could cause injury or peril to the rescuer.
Review of facility's policy titled "Emergency Procedure-Cardiopulmonary Resuscitation and Basic Life Support," dated 2001, revealed "If an individual (resident, visitor, or staff) is found unresponsive and not breathing normally, a staff member who is certified in CPR for healthcare provider/BLS (Basic Life Support) will administer CPR unless: it is known that a do not resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exist for that individual; or there is obvious signs of irreversible death (e.g. Rigor mortis). If the resident's DNR status is unclear, CPR will be initiated and continued until it is determined there is a DNR or a physician's order not to administer CPR."
Review of Resident CL1's Emergency Room hospital records dated January 15, 2026, revealed Resident CL1 admitted for diagnosis of Acute respiratory failure with hypoxia (critical condition where the lungs cannot adequately transfer oxygen to the blood), and Atrial Fibrillation (A-fib is an irregular heartbeat). The same records revealed "Code Status: Full Code."
Review of Resident CL1's "Encounter" notes by attending physician dated January 25, 2026, signed at 10:26 p.m., revealed Resident CL1 was admitted from the hospital with a diagnosis of Acute respiratory failure with hypoxia. The same note revealed "Code Status - Full code: Patient has elected Full Code status, indicating they wish to receive all possible life-saving interventions, including CPR, defibrillation (lifesaving medical procedure that uses a controlled electrical current to stop a life-threatening, chaotic heart rhythm, allowing normal heart rhythm to restore), advanced airway management, and other aggressive treatments."
Review of Resident CL1's physician's order dated January 25, 2026, revealed an order for BIPAP (Bilevel Positive Airway Pressure - noninvasive device that helps people breathe by delivering pressurized air through a mask at two distinct pressures: high for inhalation (IPAP) and low for exhalation (EPAP). Inspiratory pressure 14, Expiratory pressure 5 at bedtime.
Review of Resident CL1's nursing progress notes documented by licensed nurse Employee E4 dated February 12, 2026, at 5:10 a.m., revealed "Resident noted at 0510 without signs of life. Evidence of irreversible signs of death are pulseless, no viable vital signs, and skin cool, skin color pale and grayish, pupils dilated and fixed, no chest rise or lung sound heard. Resident pronounced by this RN (registered Nurse), family notified."
Review of statements obtained from the staff by the Director of Nursing the night of the incident revealed a statement by unlicensed Employee E5, "I [employee's name] changed [Resident CL1] at 2:30 (a.m.) [they] rolled over for me and drank some water when I went back to change [them] at 4:45 (a.m.), that's when I realized [they were] gone and I called the nurse."
Interview conducted on February 17, 2026, at 6:30 a.m.with licensed nurse Employee E4, revealed Employee E4 reported being a new nurse and employee in the facility. Employee E4 confirmed being the nurse of Resident CL1 on February 11-12, 2026, on the 11-7 shift. Employee E4 revealed that Resident CL1 was first observed at 12 midnight sleeping with BIPAP on, the resident was next observed at around 3:30 a.m., sleeping without a BIPAP mask but with a nasal cannula (flexible tube with two prongs that deliver supplemental oxygen at a low flow rate). Employee E4 reported, the resident had a habit of taking off the BIPAP mask at night. Employee E4 further revealed that before 5:00 a.m., non-licensed nursing Employee E5 called them to check the resident. Employee E4 stated, "[Resident] was lying supine, normal pale color, [resident] normally pale. I checked the pulse on the wrist and neck using my two fingers, and I did not feel a pulse. I checked the code status, but it was not listed on my sheet. Then, I saw the Nursing Supervisor, Employee E3, coming, so I called her and both of us looked for the code status, which took approximately 10 minutes. Employee E4 revealed an aide was left with Resident CL1 while checking for the resident's code status, but the code status was not on the computer. Employee E4 asked Employee E3 (nursing supervisor) what to do, and Employee E3 responded to go and get the vitals. Employee E4 reported "Resident's blood pressure, pulse rate and respirations were all "0", the temperature was 97.9 F (Fahrenheit) with the use of a thermometer machine on the forehead, resident was still kinda warm, fingertips were just turning blue, arms were both movable because I was able to put the blood pressure cuff." Employee E4 reported the above information was communicated with Employee E3 and the response was the DON (Director of Nursing) had been called. Employee E4 stated, "I was never told to do CPR or call 911."
Interview conducted with licensed nurse Employee E3 on February 17, 2026, at 7:10 a.m. revealed Employee E3 reported that on February 12, 2026, at around 5:00 a.m., Employee E4 flagged them down to come to the unit and check the resident. Employee E3 revealed Resident CL1 was "gray," cheek was cool, no breath sounds, no carotid pulse (located on either side of the neck, in the soft groove between the windpipe and the large neck muscle), no radial pulse (located on the thumb side of the inner wrist, is a primary site to measure the heart rate). Employee E3 further stated that during the assessment "I did not feel any warmth, eyes were closed, mouth was open, when I checked the wrist, I was still able to roll the arm, there was mottling (discoloration caused by reduced blood flow to the skin's surface) on the legs, they were off color but I'm not sure since I'm not familiar with the resident." Employee E3 reported that upon checking the computer, the resident's code status was full code, as indicated on the resident's preadmission report located under the miscellaneous section of the resident's EMR- Electronic Medical Record) dated January 24, 2026, the DON was called. When asked by the surveyor why CPR was not initiated, Employee E3 responded, "I do not do CPR to somebody that I assessed was already dead, no viable signs of life."
Review of Resident CL1's physician's orders revealed no order for a code status.
Interview was conducted with the DON on February 17, 2026, at 10:30 a.m. The Director of Nursing (DON) revealed the residents' code status should be reflected on the EMR (electronic medical records) in PCC (Point Click Care- electronic documentation program) below their name and on physician's orders. The DON was unable to provide an answer as to why Resident CL1's code status was not reflected in both places. The DON reported getting a call around 5:15-5:30 a.m., from Employee E3 reporting that Resident CL1 was unresponsive, was cold and "ashen" (color), starting to mottle, with no vitals and was last seen by the aide at 2:30 a.m. The DON reported asking for Resident CL1's code status, and Employee E3 responded, "I don't know, I'm looking for the advance directive (legal documents, primarily living will and durable power of attorney for healthcare that outline your preferences for medical treatments if you become unable to communicate or make decisions)." The DON reported coming to the facility around 5:50 a.m. Resident CL1's pupils were fixed and dilated. The resident was hard, ashen in color, with no vitals, the medical director was notified. The DON revealed that Employee E3 pronounced the resident dead at 5:15 a.m.
Review of Resident CL1's death certificate dated February 12, 2026, revealed the following cause of death: Cardiac Arrest (abrupt, often fatal cessation of heart function, causing immediate loss of consciousness, pulse, and breathing, requiring instant CPR and defibrillation to survive), A-fib, and Respiratory Failure.
Interview with Director of Nursing (DON) on February 17, 2026, at 10:30 a.m., revealed the facility did not initiate CPR despite information indicating the resident was a full code due to irreversible signs of death as mentioned in their interviews. The assessments mentioned in the interviews were not signs of irreversible death as indicated by the AHA guidelines and facility policy.
On February 17, 2026, at 12:12 p.m., the Nursing Home Administrator (NHA) and Director of Nursing were informed the health and safety of facility residents were in Immediate Jeopardy due to licensed nurse staff failing to provide CPR in accordance with a resident's physician encounter note and hospital documents indicating resident was a full code. The Immediate Jeopardy template was presented to the NHA and DON at this time.
The facility submitted an acceptable action plan on February 17, 2026, at 2:47 p.m. that included the following actions: A full house audit of all residents was completed to determine presence of code status and presence of a physician order; Monthly CPR drills were reviewed; Licensed staff education in CPR policy and procedures including general guidelines with focus on assessment of unresponsive residents, when to initiate CPR and identification of irreversible signs of death; Licensed staff have been taught that code status will be in PCC on the code status banner; Licensed staff have been educated in Emergency Code documentation form including the narrative of details during the code; Licensed staff have been educated in the compliance with physician orders related to the provision of CPR when indicated; Licensed staff orientation has been updated to include CPR and procedures, Emergency Code Documentation and compliance with physician order; Audit of order listing report and admission/readmission for presence of code status and corresponding order in PCC daily for seven days, three times a week for two weeks, weekly for two weeks, biweekly for two weeks then monthly for two month; Audit of effectiveness of licensed staff training will be conducted via questionnaires and on the spot interviews daily for seven days, three times a week for two weeks, weekly for two weeks, biweekly for two weeks then monthly for two months; and All ongoing compliance audits will be presented and reviewed at the QAPI meeting monthly for the next 6 months.
The Immediate Jeopardy was lifted on February 18, 2026, at 11:32 a.m., when it was confirmed the facility provided licensed nursing staff with education regarding providing CPR in accordance with residents' advanced directives, physician's orders and facility's policy, location of code status, and completed a Code drill to ensure that licensed nurses were prepared to respond to situations that required CPR. Any remaining staff were scheduled to receive the education prior to the start of their next shift.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1)(3)(e)(1) Management
28 Pa. Code 201.18(e)(3) Management
28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services
| | Plan of Correction - To be completed: 03/11/2026
The resident has expired.
2. A FULL house audit of all residents was completed to determine the presence of a CODE STATUS and presence of a physician order. No variances were found. Completed 2/17/26.
3. Immediate Actions/Education
· Monthly CPR drills were reviewed. The last drill was completed on 1/16/26 . February's drill will be held today, 2/17/26.
· Nursing Administration was educated on the frequency of required CPR drills and supplied with the 2026 Competency and Drill Schedule. Completed 2/17/2026.
· Licensed staff have been educated in Cardiopulmonary Resuscitation Policy and Procedure including general guidelines, with focus on assessment of unresponsive residents, when to initiate CPR and identification of irreversible signs of death. Education will be ongoing and done prior to the start of the shift.
· Licensed staff have been taught that code status will be in PCC on the CODE STATUS banner. Education will be ongoing and done prior to the start of the shift.
· Licensed staff have been educated in Emergency Code Documentation Form including the narrative of details during the code. Education will be ongoing and done prior to the start of the shift.
· Licensed staff have been educated in the compliance with physician orders related to the provision of CPR when indicated. Education will be ongoing and done prior to the start of the shift.
· Licensed staff orientation has been updated to include Cardiopulmonary Resuscitation policy and procedure, Emergency Code Documentation and compliance with physician orders. Education will be ongoing and done prior to the start of the shift.
4. Ongoing Compliance will be monitored by:
· Audit of Order Listing Report and Admission/Readmissions for presence of CODE STATUS and corresponding order in PCC daily for seven days, three times a week for two weeks, weekly for two weeks, biweekly for two weeks then monthly for two months.
· Audit of effectiveness of licensed staff training will be conducted via questionnaire and on the spot interviews daily for seven days, three times a week for two weeks, weekly for two weeks, biweekly for two weeks then monthly for two months.
5. All ongoing compliance audits will be presented and reviewed at the QAPI meeting monthly for the next 6 months.
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