LUBBOCK, TX - State health inspectors issued an immediate jeopardy citation to The Plaza at Lubbock after staff failed to provide basic life support to a terminally ill resident whose medical records indicated he should receive full resuscitation efforts.
The January 24, 2025 complaint investigation revealed that despite clear documentation showing the 65-year-old resident's code status as "full code," nursing staff did not initiate CPR or other basic life support measures when they found him unresponsive. Emergency medical personnel arrived to find no resuscitation efforts had been attempted by facility staff.
Breakdown in Emergency Response Protocol
The resident, who had been admitted with a diagnosis of malignant breast cancer with secondary spread to the nervous system, was designated as "full code" in his medical records. This designation means that in the event of cardiac or respiratory arrest, staff should immediately begin cardiopulmonary resuscitation and call 911. The window for effective CPR is critically narrow - brain damage can begin within 4-6 minutes of oxygen deprivation, and the chances of survival decrease by approximately 10% with each passing minute without intervention.
When staff discovered the resident unresponsive, they failed to check his code status or initiate any life-saving measures. The inspection report documented that emergency medical services arrived to find no resuscitation efforts underway. For a full code patient, this represents a fundamental breach of medical protocols that directly impacts survival outcomes.
Cardiopulmonary resuscitation must begin immediately when someone is found without a pulse or breathing. Every second counts when the brain is deprived of oxygen. The first few minutes are when CPR is most likely to be effective at maintaining blood flow to vital organs and preventing irreversible damage. Delays in starting CPR significantly reduce the likelihood of successful resuscitation and meaningful recovery.
Systemic Failures in Staff Training and Preparation
The investigation revealed that multiple staff members were unclear about how to quickly access residents' code status information. During interviews conducted as part of the corrective action verification, staff described receiving emergency training on January 24, 2025 - the same day as the inspection - covering how to locate code status documentation in the electronic medical record system.
One certified medication aide explained during the interview that nurses are supposed to carry printed lists of all residents' code statuses, while certified nursing assistants can access this information through the point-of-care system by clicking on a resident's name. However, the fact that this training occurred on the day of the inspection suggests these procedures were not consistently implemented prior to the incident.
The inability to quickly determine a resident's resuscitation preferences creates dangerous delays during medical emergencies. In facilities caring for medically complex residents, staff must be able to access code status information within seconds, not minutes. Standard nursing home protocols typically require code status to be prominently displayed in residents' charts and at bedsides, with regular staff education to ensure everyone knows where to find this critical information.
Staff interviews also revealed gaps in recognizing signs of impending death. When asked about warning signs, staff mentioned pain, increased sleeping, inability to eat or drink, and being bedbound. While these are relevant observations, they represent late-stage dying process indicators rather than the acute changes that might signal an immediate medical emergency requiring intervention for a full code resident.
Medical Implications of Code Status Confusion
Code status designations serve as legally binding medical orders that reflect a patient's wishes regarding life-sustaining interventions. "Full code" means attempt all resuscitative measures, including chest compressions, artificial ventilation, medications, and defibrillation if needed. This designation requires immediate action when a patient is found in cardiopulmonary arrest.
The distinction between recognizing someone who is actively dying versus someone experiencing a sudden cardiac or respiratory event is clinically significant. For terminally ill residents with full code status, facilities must balance providing comfort care during the dying process with being prepared to initiate aggressive interventions if the resident experiences an acute event.
Confusion about code status can lead to two types of errors: providing unwanted resuscitation to residents who have chosen comfort care only, or failing to provide desired interventions to those who want all measures attempted. Both scenarios represent failures to honor patient autonomy and medical decision-making.
Nursing homes must have clear systems to ensure staff can immediately identify each resident's wishes. This becomes particularly important during shift changes, with temporary staff, or during emergencies when stress levels are high and quick decisions must be made.
Immediate Jeopardy Designation and Required Corrections
State surveyors determined the failures created immediate jeopardy - the most serious category of nursing home deficiency, indicating a situation where the facility's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death to a resident. This designation required the facility to submit an immediate plan of correction and demonstrate that the dangerous situation had been resolved.
The facility's corrective action plan, submitted the same day as the inspection, mandated that no nursing staff could work until they completed emergency training. The Director of Nursing initiated education sessions covering proper identification of residents' code status and emergency procedures for unresponsive residents, with a deadline of 10:00 PM on January 24, 2025. Any staff who missed that deadline were required to complete training before their next shift.
The facility implemented a monitoring system requiring the Director of Nursing to audit 10 staff members weekly for four weeks. The audits assess competency in recognizing seven signs of death and active dying, nurses' ability to print and carry code status lists from the electronic medical record, and certified nursing assistants' competency in accessing code status information through the point-of-care system.
An ad hoc Quality Assurance and Performance Improvement meeting was convened with the Medical Director, facility administrator, Director of Nursing, and Social Services Director to review the removal plan. The administrator committed to forwarding monthly audit results to the QAPI Committee for review over a 90-day period.
Additional Issues Identified
The inspection noted that the facility's emergency response systems had failed to protect all residents with full code status, not just the individual involved in this incident. The corrective actions therefore extended to reviewing procedures that could affect any resident who might require emergency interventions.
Staff verification interviews conducted on January 24, 2025 by 2:30 PM showed that after the emergency training, employees demonstrated understanding of the newly reinforced procedures. One certified medication aide explained during an interview at 11:34 AM that the Director of Nursing had trained staff on locating code status information and recognizing signs of death, including knowing when to call for help and maintain visual observation of residents showing concerning symptoms.
The facility's quality assurance committee received documentation of all staff education to verify completion and maintain records of the systematic changes implemented to prevent recurrence.
Inspection Details: - Facility: The Plaza at Lubbock, 4910 Emory, Lubbock, TX 79416 - Inspection Date: January 24, 2025 - Inspection Type: Complaint investigation - Citation: F678 - Emergency care/transfers (Immediate Jeopardy) - Scope: Few residents affected
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Plaza At Lubbock from 2025-01-24 including all violations, facility responses, and corrective action plans.
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