PALM COAST, FL - Federal inspectors found that Grand Oaks Health and Rehabilitation Center failed to provide cardiopulmonary resuscitation to a resident who had requested full life-saving measures, leading to immediate jeopardy findings and raising serious questions about emergency response protocols at the facility.
Critical Failure in Emergency Response
The June 2024 inspection revealed a devastating breakdown in emergency protocols when nursing staff discovered an unresponsive resident but failed to initiate CPR despite clear orders requiring full resuscitation efforts. The resident, who had been admitted for short-term skilled care following treatment for acute systolic congestive heart failure and chronic respiratory conditions, was found unresponsive in his room during morning care rounds.
According to facility documentation, a certified nursing assistant making morning rounds at approximately 7:30 a.m. discovered the resident unresponsive in his bed. The resident had complex medical conditions including chronic obstructive pulmonary disease, acute pulmonary edema, and atherosclerotic heart disease, but had explicitly requested full code status - meaning he wanted all life-saving measures including CPR if needed.
The inspection found that despite facility policies requiring immediate CPR for any resident without a do-not-resuscitate order, nursing staff failed to begin life-saving measures. The weekend supervisor, a registered nurse who was still in orientation, made an unauthorized decision to pronounce the resident deceased without attempting resuscitation.
Falsified Documentation and Cover-Up Attempts
Investigation revealed that nursing staff initially provided false statements about performing CPR when they had not done so. Multiple staff members later admitted during follow-up interviews that CPR was never performed, despite initial documentation claiming otherwise.
One nursing assistant stated during interviews: "When the Administrator arrived, she was pressuring CNA D for a statement while the ADON tried to come up with a story to cover things up." Another staff member reported being told they "needed to keep their stories straight, and say CPR was performed for three minutes."
The registered nurse supervisor later admitted: "CPR was never done, not once. RN A said, I wouldn't do that to a dead body; you wouldn't want that done to your loved one." This statement directly contradicted facility policy requiring CPR for all residents with full code status, regardless of apparent signs of death.
Emergency medical services personnel who responded to the scene reported that the resident "had to have been dead for two to three hours" based on the condition of the body when they arrived. However, this assessment should not have prevented CPR attempts according to established nursing home protocols.
Breakdown in Training and Supervision
The investigation revealed significant failures in staff training and supervision that contributed to the emergency response breakdown. The registered nurse who made the decision not to perform CPR had received inadequate orientation, completing only a brief training session before being placed in a supervisory role.
During interviews, the nurse stated: "Her new employee orientation Friday was fast because the facility needed her. She got no training, just a stack of papers to sign, and then was sent with LPN A to shadow her on the medication cart." This abbreviated orientation failed to properly prepare the nurse for emergency situations or clarify facility policies regarding resuscitation.
The facility's cardiopulmonary resuscitation policy clearly states that "CPR will be provided to all residents who are identified to be in cardiac arrest unless such resident has a fully executed Florida Do Not Resuscitate order." The policy further specifies that "center staff will continue performing CPR until Emergency Medical Technicians assume responsibility for CPR."
Medical professionals emphasize that CPR training and protocols exist specifically to provide residents with every possible chance of survival, even when the situation appears hopeless. The decision to withhold CPR based on visual assessment of the body's condition violates fundamental principles of emergency medical care and the resident's explicitly stated wishes for full resuscitation efforts.
Medical Significance of the Violations
The resident's medical conditions, while serious, did not preclude the possibility of successful resuscitation. Patients with congestive heart failure and chronic obstructive pulmonary disease can experience sudden cardiac events that may be reversible with prompt intervention. The combination of his conditions - including acute systolic heart failure and chronic respiratory failure - made immediate medical intervention even more critical.
Current medical standards emphasize that apparent signs of death can be misleading, particularly in patients with chronic conditions that may cause color changes or reduced responsiveness. Only trained emergency medical personnel or physicians are qualified to make determinations about the viability of resuscitation efforts.
The failure to attempt CPR deprived the resident of potentially life-saving measures that he had specifically requested. Advanced cardiac life support protocols are designed to provide multiple opportunities for return of spontaneous circulation, even in patients who initially appear unresponsive.
Research shows that immediate CPR can double or triple survival rates from cardiac arrest. The delay in emergency response and complete failure to attempt resuscitation eliminated any possibility of recovery, regardless of the underlying prognosis.
Industry Standards and Required Protocols
Federal regulations require nursing homes to maintain clear advance directive policies and follow residents' specific wishes regarding life-sustaining treatment. When residents choose full code status, facilities must be prepared to provide immediate emergency response including CPR, regardless of staff assessments about the likelihood of success.
Professional nursing standards mandate that only licensed physicians or emergency medical personnel can pronounce death and make decisions about terminating resuscitation efforts. Nursing home staff lack the authority to override a resident's advance directive based on their own clinical judgment about the futility of treatment.
The facility's own policies aligned with these standards, requiring immediate CPR initiation and continuation until emergency medical services assumed responsibility. The breakdown occurred not in policy development but in implementation and staff compliance with established protocols.
Administrative Response and Improvements
Following the incident, facility administrators conducted multiple investigations and implemented corrective measures. The facility held emergency Quality Assurance Performance Improvement meetings to address the violations and develop prevention strategies.
Corrective actions included comprehensive retraining on advance directives, CPR protocols, and ethics compliance. The facility audited all resident code statuses to ensure accuracy and implemented regular Code Blue drills for all licensed staff. Additionally, administrators enhanced orientation procedures to prevent inadequately trained staff from being placed in supervisory positions.
The facility also addressed the compliance and ethics issues revealed during the investigation, providing building-wide training on reporting concerns without fear of retaliation and appropriate responses when asked to engage in unethical behavior.
Additional Issues Identified
The inspection documented several other concerning practices including inadequate staff orientation procedures, unclear chain of command during emergencies, and insufficient oversight of nursing staff decision-making. The facility's initial investigation also revealed problems with documentation accuracy and staff communication during crisis situations.
Inspectors noted deficiencies in the facility's process for ensuring all staff understand advance directive requirements and the legal obligations surrounding resuscitation decisions. The investigation highlighted the need for clearer protocols regarding when emergency medical services should be contacted and how staff should respond to apparent death situations.
Federal inspectors initially determined the violations posed immediate jeopardy to resident health and safety, though this designation was later removed following the facility's implementation of corrective measures and demonstrated compliance with emergency response requirements.
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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