Titusville Rehab: CPR Delayed Hours for Dying Resident - FL
The resident was found without pulse or breathing sometime between 2:30 AM and 3 AM, but CPR wasn't initiated until after 6 AM while staff called back and forth with hospice services to clarify whether the man wanted to be resuscitated.
Federal inspectors who investigated the incident at Titusville Rehabilitation & Nursing Center found that nursing staff had been trained to follow physician orders in the electronic medical record, not to consult hospice documentation. But Licensed Practical Nurse A looked in the hospice binder anyway and found a do-not-resuscitate order that contradicted the facility's full-code status for the patient.
"I just need to know whether he is a full DNR or not," LPN A told the hospice triage nurse during a recorded call at 6:15 AM, more than three hours after the resident was discovered unresponsive.
The resident's medical records showed he had been on hospice care for moderate protein-calorie malnutrition but had specifically chosen to remain a "full code" for resuscitation. A progress note from an advance care planning meeting stated: "Resident chooses to remain a full code at this time."
Yet hospice records contained contradictory orders. One document dated two days before the resident's death listed "Do Not Resuscitate," while another from the same period noted "Resuscitate."
Certified Nursing Assistant B, who found the resident, told investigators she alerted LPN A immediately. "I told [LPN A's name] he wasn't breathing," CNA B wrote in a statement. "She checked the computer and she said he was a DNR. She called the hospice and they confirmed he was a DNR. Then about an hour later hospice called back and said he was a full code, so she went back to the room and started doing CPR."
The delay proved fatal. Emergency Medical Services records show staff told paramedics the resident "was last seen normal at 1:00 AM during medication administration" and was "found unresponsive, pulseless, apneic" around 6:30 AM. EMS noted there was a "delay in initiating CPR over confusion involving patient's DNR."
The resident died at the hospital at 7:13 AM.
Multiple versions of events emerged during the investigation, with timelines shifting dramatically between interviews and documentation. The facility's Code Blue Worksheet initially listed the discovery time as 6:15 AM. But CNA B later told investigators she found the resident unresponsive between 2:30 AM and 3 AM.
LPN A provided conflicting accounts. In one interview, she said she was notified around 5 AM to 6 AM. In another statement, she said CNA B found the resident around 5:30 AM. The hospice call transcript shows LPN A reporting at 6:09 AM that the "patient expired at 6:00."
"She would not forget this event, because it was her first death," investigators wrote about CNA B's testimony.
The Corporate Director of Risk Management acknowledged the contradictions created serious questions about the facility's response. Hospital documentation indicated "no bystander CPR" was provided, conflicting with facility claims that staff performed compressions.
Emergency Medical Services arrived at 6:41 AM and found staff had initiated CPR approximately five to ten minutes before their arrival, according to the EMS report. This timeline suggested CPR began around 6:30 AM, not at 6:17 AM as documented on the facility's Code Blue worksheet.
The facility's own Medical Director, who wasn't involved in the incident, told inspectors the education provided to nurses was "lacking." He said some newer nurses incorrectly believed that residents receiving hospice services automatically had do-not-resuscitate orders.
"The facility needed to review and put some education in place," the Medical Director stated.
The only documentation in the resident's medical record about the entire incident was a single progress note at 6:29 AM stating: "Patient has expired Hospice notified MD notified."
No record existed of when the change in condition was first identified, what assessments were performed, or what actions staff took during the hours between discovery and death. LPN A told investigators the information was documented on a CPR log given to the former Director of Nursing, but acknowledged "the information was not documented in the resident's clinical record."
When asked why proper documentation wasn't completed, LPN A said "she was tired."
The facility's own policy required that "Code Status and resident will be verified by 2 identifiers with another nursing care center personnel" before initiating CPR. The policy also mandated that licensed practical nurses "handle emergency situations in a prompt, precise, and professional manner" and "maintain accurate, detailed reports and records."
Federal inspectors found the facility failed to follow its own protocols on multiple levels. Staff didn't verify the code status with a second nurse as required. The investigation was inadequate, with statements not obtained from key personnel until months later during the federal inspection. Critical documentation was missing from medical records.
The Corporate Director of Risk Management admitted the facility's investigation left her "with questions" about what actually happened. She acknowledged conflicts between staff statements, interviews, timeline documentation, and external medical records.
In response to the immediate jeopardy finding, the facility implemented emergency measures including mandatory education for all 31 licensed nurses on code status procedures. Staff completed nine Code Blue drills across all shifts. The facility audited all 100 residents' advance directives and combined hospice charts with facility records to eliminate separate binders that had caused confusion.
The resident had been admitted to the facility months earlier with multiple conditions including diabetes, anemia, and repeated falls. His cognitive assessment showed he was mentally intact with a score of 13 out of 15 on standard testing.
Despite being on hospice care, he had specifically requested full resuscitation measures during advance care planning meetings. The contradiction between his expressed wishes and the delayed response that followed his collapse represents exactly the kind of systematic failure that federal immediate jeopardy citations are designed to address.
The investigation revealed a facility where critical policies weren't followed, staff training was inadequate, documentation was falsified or omitted entirely, and a resident's final wishes were ignored during his last hours of life.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Titusville Rehabilitation & Nursing Center from 2024-06-07 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
TITUSVILLE REHABILITATION & NURSING CENTER in TITUSVILLE, FL was cited for violations during a health inspection on June 7, 2024.
"I told [LPN A's name] he wasn't breathing," CNA B wrote in a statement.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.