PALM COAST, FL - Federal inspectors cited Grand Oaks Health and Rehabilitation Center for immediate jeopardy violations after nursing staff failed to perform CPR on an unresponsive resident with full-code status, then created false documentation claiming they had provided lifesaving care.
The June 7, 2024 complaint investigation revealed a cascade of protocol failures that began when staff discovered a 77-year-old resident unresponsive in his room and ended with multiple nurses admitting they fabricated records about performing cardiopulmonary resuscitation.
Discovery and Protocol Violations
On the morning of the incident, a certified nursing assistant making morning rounds discovered the resident unresponsive in his bed at approximately 7:30 a.m. The resident had been admitted for short-term skilled care following hospitalization for acute systolic congestive heart failure, chronic respiratory failure, pulmonary edema, and chronic obstructive pulmonary disease. His physician's orders clearly documented full-code status with plans to discharge home.
When staff found the resident, he showed no signs of breathing or pulse. His oxygen tubing was on the floor with the concentrator still running. Multiple staff members observed that his lips, fingers, toes, and ears appeared blue, and his body felt cold and stiff to the touch.
Despite these findings and the resident's documented full-code status, the registered nurse serving as weekend supervisor that day made a unilateral decision not to initiate CPR. According to witness statements collected during the facility's investigation, the RN assessed the resident, determined he had been deceased for some time, and pronounced him dead - an action that violated both facility protocol and Florida regulations that prohibit nurses from pronouncing death.
Facility Protocol Requirements
The facility's cardiopulmonary resuscitation policy, effective since 2008, established clear procedures for responding to cardiac arrest. The policy mandated that CPR be provided to all residents in cardiac arrest unless a fully executed Florida Do Not Resuscitate order was present in the medical record.
The protocol required two licensed nurses to verify both resident identification and the presence of any DNR order. In the absence of such an order, staff were directed to immediately begin CPR and continue until emergency medical technicians assumed responsibility or the resident responded.
According to the policy, staff were required to use the paging system to call "Code Blue" three times and continue performing CPR until EMS personnel arrived and took over care. The protocol made no exceptions for apparent signs of death when a resident held full-code status.
Medical standards for CPR initiation exist because determining death with certainty requires specific clinical assessments and, in most healthcare settings, physician or paramedic confirmation. Signs such as rigor mortis, dependent lividity, and body cooling can help indicate death has occurred, but facility nurses are not authorized to make this determination independently. The standard of care requires initiating resuscitation for any unresponsive person with no pulse or breathing unless a valid DNR order exists.
Emergency Response Breakdown
When the Code Blue was announced overhead, multiple licensed nurses responded to the resident's room. However, the supervising RN turned them away, stating there was nothing to code and that the resident had been deceased for too long. One licensed practical nurse specifically asked whether they should perform CPR, but was told by the supervisor that the resident "had been dead for a while and there's nothing we can do."
The facility called emergency medical services, but when paramedics arrived, the supervising nurse stopped them before they could enter the room and assess the resident. She informed EMS that she had pronounced the resident deceased. The paramedics left without examining the patient.
This initial dismissal of EMS violated standard emergency protocols. Emergency medical technicians are trained and authorized to confirm death in the field using specific criteria. By preventing their assessment, the facility denied the resident the full emergency response his code status required.
Administrative Intervention and False Documentation
After the supervising RN contacted facility administrators about the death, the nursing home administrator instructed her to initiate CPR immediately. However, by this point, approximately 30 minutes had elapsed since staff first discovered the resident unresponsive.
The facility called EMS back to the scene. When paramedics returned at 8:15 a.m., they placed monitoring leads on the resident and officially pronounced him deceased at 8:20 a.m. - nearly an hour after staff first found him unresponsive.
The breakdown in emergency response created serious questions about whether the resident received the care his advance directive status guaranteed. Full-code status represents a resident's explicit wish to receive all available lifesaving measures, including chest compressions and emergency interventions. When facilities fail to honor this choice, they violate both regulatory requirements and the resident's fundamental right to make decisions about end-of-life care.
Investigation Reveals Fabricated Records
Following the incident, facility administrators collected written statements from staff members present during the emergency. Initial statements from the supervising RN and the resident's assigned licensed practical nurse both claimed they had performed CPR for approximately five rounds, or 15 minutes, before the RN pronounced the resident's death.
These initial statements formed the basis of the facility's first report about the incident. However, discrepancies in the timeline soon raised questions about the accuracy of these accounts.
According to subsequent investigation findings, a certified nursing assistant who witnessed the events came forward several days later and reported that no CPR had been performed. The CNA stated that after discovering the resident unresponsive, she observed nursing staff arguing near the doorway about whether to initiate resuscitation. She reported seeing the RN perform "pretend CPR with hand movements" over the resident's body, but witnessed no actual chest compressions.
The CNA also reported that one of the licensed practical nurses approached her and other nursing assistants after the incident and told them they "needed to keep their stories straight" and say that CPR was performed for three minutes.
Staff Admissions and Allegations of Coercion
When the facility's Regional Nurse Consultant conducted follow-up interviews, multiple staff members changed their initial statements and admitted that CPR was never performed. The supervising RN confirmed she had assessed the resident, determined he was deceased, and refused to initiate chest compressions despite being told he was full code. She stated her assessment found the resident pulseless, without respirations, stiff, and cold to the touch with blue discoloration of the extremities.
According to her revised statement, the RN felt that performing CPR on someone she believed to be deceased would be "defiling a body" and refused to do so despite protocol requirements and direction from other staff.
The licensed practical nurse assigned to the resident also changed her statement during the regional investigation. She admitted that no CPR was performed and alleged that the nursing home administrator had pressured her to falsify her documentation. According to her statement, she was told that if she did not document that CPR had been performed, she could lose her nursing license. She reported feeling "cornered and threatened" and believed she had no choice but to comply with what she perceived as directions from facility leadership.
The nursing home administrator strongly denied these allegations when interviewed by state inspectors. She stated that she had reminded the LPN that the resident was her responsibility and asked what had happened, but denied instructing anyone to falsify documentation or threatening any staff member's license.
Facility Response and Corrective Actions
Following the substantiated allegation of neglect, the facility convened an Ad Hoc Quality Assurance Performance Improvement committee meeting and developed a comprehensive performance improvement plan. The initial root cause analysis focused on inadequate orientation for the supervising nurse, who had been hired on Friday and was found working in a supervisory capacity by Sunday despite being scheduled for orientation.
When the falsified documentation came to light, the facility held a second Ad Hoc QAPI meeting to address ethical conduct and compliance issues. The corrective action plan included several components:
Staff Education: The facility provided training on advance directives, CPR policy, abuse and neglect prevention, and ethical documentation practices to all licensed staff. Education emphasized that nurses must follow facility protocols and cannot independently decide whether to honor a resident's code status based on personal assessment.
Competency Validation: All licensed nurses received testing on CPR protocols, with 100% required to pass. The facility verified that all nursing staff held current American Heart Association CPR certification.
Policy Review: Weekly audits of advance directive documentation were implemented to ensure all residents had current, accurate code status orders in their medical records.
Code Blue Drills: Regular emergency response drills were scheduled with mandatory participation from all licensed nursing staff to reinforce proper protocols.
Compliance Training: Building-wide training addressed how to report concerns about unethical requests without fear of retaliation and what steps to take if asked to do something that violated professional standards.
The facility also revised its orientation process to include classroom-based training for new nurses with documented completion audits before staff could work independently.
Regulatory Violations and Immediate Jeopardy
The Centers for Medicare & Medicaid Services cited the facility for violation of 42 CFR 483.12(a), which requires nursing homes to ensure each resident receives care in accordance with professional standards of practice. The citation reached the level of immediate jeopardy - the most serious deficiency category - indicating that the facility's practices caused or were likely to cause serious injury, harm, impairment, or death to residents.
Federal regulations require nursing facilities to provide necessary care and services to help each resident attain or maintain their highest practicable physical, mental, and psychosocial well-being. This includes honoring residents' advance directives and code status preferences.
When facilities fail to initiate CPR for full-code residents experiencing cardiac or respiratory arrest, they deny residents the opportunity for resuscitation that might restore life or buy additional time for family to arrive. While CPR success rates vary based on numerous factors including underlying health conditions and time elapsed since cardiac arrest, the decision to attempt resuscitation must rest with the resident's documented wishes, not staff judgment about likely outcomes.
The falsification of medical records compounded the initial protocol failure by creating documentation that misrepresented the care provided. Accurate medical records are essential for quality improvement, regulatory compliance, and maintaining trust in the healthcare system. When staff falsify records, it becomes impossible to conduct meaningful analysis of what went wrong and implement appropriate corrective actions.
Impact on Residents and Families
The resident who died in this incident had been admitted for short-term skilled care with an expected discharge home to his spouse. His medical conditions included serious cardiac and respiratory diagnoses that carried significant health risks, but his physician had not recommended comfort care or do-not-resuscitate status. Instead, his orders reflected goals of treatment and eventual discharge home.
When nursing staff failed to honor his full-code status, they denied him the emergency response he had specifically requested through his advance care planning. While the likelihood of successful resuscitation may have been limited given his complex medical history and the apparent time elapsed since he stopped breathing, the decision not to attempt CPR removed any chance of survival.
The facility's Medical Director, when interviewed about the incident, noted that while the resident's chances of recovery were minimal given his COPD and congestive heart failure diagnoses, he was entitled to have CPR initiated based on his documented full-code status. The Medical Director characterized the nurse's independent decision not to provide CPR as a mistake that affected the entire facility's reputation and resident trust.
Broader Implications for Nursing Home Care
This incident highlights several systemic issues that can affect quality of care in nursing homes. Inadequate orientation for new staff, particularly those in supervisory roles, can create dangerous gaps in knowledge about facility-specific protocols and regulatory requirements. When nurses work in unfamiliar settings without proper training, they may default to assumptions or prior practices that do not align with current facility policies.
The allegations of pressure to falsify documentation, whether substantiated or not, point to the critical importance of establishing a culture where staff feel safe reporting adverse events truthfully. Quality improvement depends on accurate information about what occurred during incidents. When staff fear professional consequences for reporting protocol violations, facilities lose the opportunity to identify and correct systemic problems before they harm additional residents.
The incident also underscores the importance of clear policies about code status verification and emergency response. While the facility had written protocols in place, the breakdown occurred when an individual nurse made independent decisions that contradicted those policies. Effective implementation requires not only written procedures but also regular training, competency validation, and a culture that supports compliance even in challenging situations.
For complete inspection details and the facility's specific corrective action timeline, the full report is available through the Florida Agency for Health Care Administration and Centers for Medicare & Medicaid Services.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Grand Oaks Health and Rehabilitation Center from 2024-06-07 including all violations, facility responses, and corrective action plans.
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