What are the best practices to prevent a deficiency, especially an Immediate Jeopardy, related to CPR?




One of the most critical components in preventing a deficiency related to CPR is communication. The facility must ensure that the resident’s admission documentation clearly identifies code status and/or Advance Directives. The designated code status must be documented in all of the areas addressed in the facility policy/procedure and must also be communicated to all staff in the manner directed by this policy/procedure. For example, if a specified sticker is to be used on designated areas such as the room nameplate, the resident’s headboard, or on the paper chart (if utilized), then there must be a process in place to make sure these are all in place. If any type of bracelet or other identification ‘jewelry’ is utilized, these must also be verified as in place and monitored on a regular basis.

Timely follow-up must be done to determine that all needed paperwork is obtained and included in the resident’s record as close to the time of admission as possible. If a MOST or POLST form has already been implemented, a copy must be obtained for the facility records and reviewed in accordance with the state requirements. Additional EMS type forms for DNR may also need to be completed with the necessary signatures obtained as quickly as possible as these are needed by these frontline workers for resident transfers, both emergency and non-emergency.

Residents and their representatives may change their code status at any time if they meet the legal requirements to do so (i.e., resident has not been deemed incompetent, representative has paperwork to support their legal authority). To ensure that these changes are communicated, the resident’s code status documentation should be reviewed as part of the quarterly care plan meetings, and with any significant changes in the resident’s status.

Another critical component in preventing deficiencies relating to CPR is staff education, not only on the correct CPR techniques but on the process for immediately verifying code status and implementing CPR if the resident is designated as a full code. The most significant deficiencies usually result from staff failure to initiate CPR timely without the required reasons that support withholding this lifesaving procedure, which include:

      • a valid DNR order is in place;
      • obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition) are present; or
      • initiating CPR could cause injury or peril to the rescuer

Unless one or more of these criteria are present, CPR should be immediately initiated and continued until the arrival of emergency personnel to take over the code in progress.

Janine Lehman, RN, RAC-CT, CLNC
Director of Legal Nurse Consulting

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