In this self reported incident investigation and partial survey, the facility failed to provide CPR. Based on closed clinical record review, interview with facility staff and an X-ray Technician, review of the policy and procedure for "Emergency or Acute Treatment-Long term Care", the facility failed to provide necessary care and services when nursing staff did not implement Cardiopulmonary Resuscitation (CPR) for a Resident. This resulted in Immediate Jeopardy for one of 10 sampled residents. The facility identified 31 residents with "Full Measures" advanced directives for CPR. On 02/11/10, the Administrator and the Director of Nursing were notified Immediate Jeopardy began on 01/30/10 when facility staff found Resident unresponsive, not breathing and without vital signs. LPN #10 and LPN #11 did not initiate CPR or call emergency medical service (EMS/or 911).
What actions would you and your staff members take to prevent this from occurring in your facility?
Could this happen at your facility?
Share your thoughts and ideas about our monthly Challenge Scenarios (based on real life examples) with a collaborative community dedicated to improving care.
Share your thoughts and ideas about our monthly Challenge Scenarios (based on real life examples) with a collaborative community dedicated to improving care.
1. A nurse must always initiate CPR upon finding a resident who is not a DNR without pulse and respirations. The physician is the only person who can tell the nurse to discontinue CPR. Standard emergency procedures should also include obtaining help/assistance.
ReplyDelete2. Assure that facility staff nurses are up to date with current standards for CPR based on the American Heath Association.
3. Nurses may not pronounce death; they may call the physician, or advance practice nurse, and report the absence of vital signs.
A consistent, easy to follow, preferably one-step system is recommended as the best assurance that all staff will understand it, and that is easiest to keep accurate and up to date. Systems that rely on secondary identification, such as a chart label or ID bracelet, can often be confused and not updated if a resident’s code status changes. Suggest the consideration of a separate "Advance Directives" tab in the front section of the chart that all appropriate staff is aware of and can easily access in time of need. If a system must be used that lists individuals' code status in a location secondary to the medical record, a strong system that includes checks and balances must be adopted to ensure accuracy, in addition to additional staff education.