CONVERSE, TX - Federal inspectors found that Rosewood Rehabilitation and Care Center failed to initiate cardiopulmonary resuscitation for a resident designated as "full code" who was discovered without a pulse, leaving the individual without potentially life-saving intervention for over an hour before emergency medical services arrived.
Critical Delay in Emergency Response Procedures
The most serious violation documented during the July 27, 2024 inspection occurred when a nurse discovered an unresponsive resident at 10:02 PM but failed to immediately check the resident's code status or initiate CPR. According to the inspection report, the resident remained without pulse or respirations until Emergency Medical Services arrived at 11:23 PM - a critical 81-minute delay.
The resident was classified as "full code," meaning they had specifically requested all life-sustaining measures, including CPR, be performed in the event of cardiac or respiratory arrest. Despite this clear directive, nursing staff did not follow the facility's own emergency protocols.
The licensed vocational nurse involved in the incident was terminated following an investigation. The facility's medical director was notified at 12:02 PM the following day but provided no additional instructions regarding the incident response.
Understanding Code Status and Emergency Protocols
In healthcare settings, a patient's "code status" determines what level of medical intervention should be provided during life-threatening emergencies. Full code status means healthcare providers should perform all available resuscitation measures, including chest compressions, artificial ventilation, medications, and electrical cardioversion if necessary.
When a person experiences cardiac arrest, brain cells begin dying within 4-6 minutes due to lack of oxygen. Immediate CPR can double or triple a person's chance of survival by maintaining blood circulation and oxygen delivery to vital organs until advanced medical care arrives. The American Heart Association emphasizes that prompt recognition and immediate action are critical factors in successful resuscitation outcomes.
The failure to provide timely CPR represents a fundamental breach of established medical protocols. Current guidelines recommend that healthcare providers immediately assess responsiveness, check for breathing and pulse, and begin chest compressions within 10 seconds of recognizing cardiac arrest in patients with full code status.
Facility's Corrective Action and Staff Training
Following the incident, Rosewood Rehabilitation implemented comprehensive corrective measures. The Director of Nursing conducted mandatory training for all licensed nursing staff on July 29, 2024, covering resident code status verification, hospice care protocols, and emergency response procedures.
The training emphasized several key points: hospice residents can elect to remain full code, nurses must immediately check code status in the electronic medical record when finding unresponsive residents, and staff must initiate CPR while simultaneously calling for emergency assistance. A flow chart outlining proper response procedures was posted at nursing stations as a visual reminder.
The facility completed a 100% audit of all 59 residents' code status documentation, verifying that face sheet information matched physician orders. The audit revealed 31 residents with full code orders and 28 with do-not-resuscitate (DNR) orders. Of the 10 residents receiving hospice care, three maintained full code status.
Post-training assessments confirmed that all nursing staff could correctly identify where to locate code status information, understand hospice patients' rights to remain full code, and demonstrate knowledge of appropriate emergency responses.
Industry Standards for Emergency Preparedness
Healthcare facilities are required to maintain emergency preparedness programs that ensure rapid response to medical emergencies. The Centers for Medicare & Medicaid Services mandates that nursing homes have policies and procedures for emergency situations, including cardiac arrest.
Best practices for code status management include clear documentation in easily accessible locations, regular staff training on emergency protocols, and immediate response systems. Many facilities use electronic medical records with prominently displayed code status indicators and automated alert systems to ensure staff can quickly access this critical information.
The Joint Commission, which accredits healthcare organizations, requires that resuscitation policies address the roles and responsibilities of all staff members, communication procedures, and documentation requirements. Facilities must also demonstrate competency through regular drills and ongoing education.
Research indicates that nursing home residents who receive immediate CPR have significantly better outcomes than those who experience delays in treatment. Studies show that survival rates decrease dramatically with each minute of delay, making prompt recognition and response essential.
Monitoring and Quality Assurance Measures
Rosewood Rehabilitation established ongoing monitoring systems to ensure sustained compliance with emergency protocols. The Administrator implemented weekly random testing of nursing staff for four consecutive weeks, assessing their knowledge of code status procedures and emergency response requirements.
The Director of Nursing created audit logs to conduct random assessments of licensed nurses, including verification of residents' code status, hospice enrollment, and appropriate response protocols. These audits document whether staff can correctly identify code status and demonstrate understanding of required actions.
New hires receive orientation training on code status procedures, while agency staff receive education before beginning their shifts. The facility maintains documentation of all training activities and competency assessments to ensure consistent knowledge across all nursing personnel.
The inspection report noted that federal surveyors confirmed the facility had implemented sufficient corrective measures to address the immediate jeopardy finding. However, the facility remained under increased scrutiny to monitor the effectiveness of their improvement plan.
Regulatory Consequences and Ongoing Oversight
The violation was classified as "immediate jeopardy," the most serious level of noncompliance, indicating situations that pose serious injury, harm, impairment, or death to residents. This designation requires facilities to immediately implement corrective actions and submit detailed plans of correction to state and federal regulators.
While the immediate jeopardy designation was removed after the facility demonstrated adequate corrective measures, inspectors continued monitoring to ensure sustained compliance. The facility must maintain documentation of all training activities, audits, and competency assessments for regulatory review.
Federal regulations require nursing homes to provide necessary care and services to help residents achieve their highest practicable physical, mental, and psychosocial well-being. The failure to provide timely emergency care represents a significant breach of these fundamental obligations to resident safety and welfare.
This incident highlights the critical importance of proper emergency preparedness training and the life-threatening consequences that can result from procedural failures in healthcare settings. Nursing home residents, who often have complex medical conditions and increased vulnerability, depend on skilled nursing staff to provide appropriate care during medical emergencies.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rosewood Rehabilitation and Care Center from 2024-07-27 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.