GRAPEVINE, TX - Federal health inspectors cited Birchwood of Grapevine for immediate jeopardy violations after nursing staff failed to provide life-saving CPR to an unresponsive resident, contributing to the patient's death due to confusion over advance directive documentation.
Critical CPR Failure Results in Death
The most serious violation occurred when Licensed Vocational Nurse A discovered an elderly male resident lying face-down on a fall mat in his room during evening rounds. The resident's face appeared "reddish purple" with only a weak pulse detected and no visible breathing patterns observed.
Despite finding the resident in obvious medical distress, the nursing staff failed to immediately initiate cardiopulmonary resuscitation. Instead, they placed the resident on oxygen and began searching through electronic records to determine his code status - a delay that proved fatal.
The resident had been admitted as a "full code" patient, meaning all life-saving measures should have been attempted. However, nursing staff became confused by a hospital DNR (Do Not Resuscitate) order that was not valid for nursing home settings under Texas law.
Emergency Medical Response Reveals Fatal Delay
When Emergency Medical Services arrived approximately 15 minutes later, they found the resident "pulseless and apneic" (without heartbeat or breathing). Fire department personnel immediately began advanced cardiac life support measures, but the resident remained in cardiac arrest throughout transport to the hospital, where resuscitation efforts were ultimately discontinued.
The EMS Captain who responded to the emergency later expressed serious concerns about the facility's handling of the incident. "There was so much confusion on whether a resident was a DNR or a full code," he stated during follow-up interviews with inspectors.
According to Texas regulations, nursing homes must have state-recognized "Out of Hospital DNR" documentation for residents who wish to refuse resuscitation. Hospital DNR orders are not valid in nursing home settings, meaning any resident without proper documentation must be treated as full code status.
Medical Standards Require Immediate Action
When a resident is found unresponsive without clear breathing, medical protocols require immediate assessment and intervention. CPR should begin within minutes of discovering an unresponsive patient, as brain damage can occur within 4-6 minutes without oxygen.
The facility's own emergency procedures policy clearly states that "if the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR."
The nursing staff's failure to follow this protocol represented a critical breakdown in emergency response that federal inspectors determined posed immediate jeopardy to resident health and safety.
Pattern of Abuse and Neglect Violations
The CPR failure was not an isolated incident. Inspectors documented multiple serious violations during their March 2025 investigation, including a resident-to-resident assault that resulted in immediate jeopardy status.
Resident Assault Causes Pelvic Fracture
In January 2025, an elderly female resident with dementia pushed another resident to the floor during an argument in the dining area. The victim, who had been independently mobile before the incident, experienced immediate pain and was initially given medication and kept for observation.
Initial X-rays appeared negative for fractures, but when the resident continued experiencing severe pain the following day, she was transported to the hospital. Advanced imaging revealed multiple pelvic fractures including breaks in the anterior left acetabulum, left inferior pubic ramus, and left sacrum.
The victim, who previously walked independently, now requires wheelchair assistance for mobility. Her family reported the dramatic change in her functional status, noting she could only take a few painful steps before needing to sit down.
Failure to Report Abuse Promptly
Federal regulations require nursing homes to report suspected abuse to administrators immediately, and to state authorities within two hours for incidents causing serious bodily injury. However, the nursing staff who witnessed the assault failed to properly report it as abuse.
The Licensed Vocational Nurse who documented the incident wrote that the resident was "pushed to floor by another resident" but did not immediately notify the Administrator, who serves as the facility's Abuse Coordinator. The nurse later explained she "did not think it was abuse at the time" because the aggressive resident had dementia.
Similarly, the Certified Nursing Assistant who directly witnessed the assault stated she "was not sure why she did not report the situation to the Administrator," despite receiving training on abuse reporting procedures.
The Administrator's investigation was inadequate, as she only spoke with one staff member and failed to interview the direct witness to the incident. She also did not report the incident to state health authorities as required by law.
Theft of Resident Funds
In a separate incident, the facility failed to protect residents from financial exploitation when a newly-hired Certified Nursing Assistant stole a resident's debit card and used it for personal purchases.
The theft was discovered when the resident's family noticed suspicious charges totaling $259 at three local businesses. Security camera footage from one of the businesses allowed facility management to identify the employee, who was terminated after refusing to provide a statement about the allegations.
The incident highlights vulnerabilities in the facility's oversight of staff access to resident belongings and personal property.
Systemic Training and Oversight Failures
The pattern of violations revealed significant gaps in staff training and administrative oversight. Despite having policies prohibiting abuse and requiring immediate reporting, staff demonstrated poor understanding of their responsibilities.
The facility's response to these violations included comprehensive retraining of all staff on abuse recognition, reporting procedures, and emergency response protocols. Management also implemented daily behavioral assessments and weekly interdisciplinary team reviews to monitor residents at risk for aggressive behaviors.
For the CPR violation specifically, the facility conducted audits of all residents' advance directive documentation and provided enhanced training on distinguishing between valid and invalid DNR orders.
Regulatory Consequences and Monitoring
Federal inspectors removed the immediate jeopardy designations after the facility demonstrated corrective actions, but continued monitoring the effectiveness of implemented changes. The facility remained in violation at reduced severity levels while proving the sustainability of their improvements.
The Centers for Medicare & Medicaid Services may impose additional penalties including fines or restrictions on new admissions for facilities with immediate jeopardy violations.
These incidents underscore the critical importance of proper emergency response training, clear abuse reporting procedures, and robust oversight of resident care in nursing home settings. Families considering nursing home placement should inquire about staff training protocols and emergency response procedures when evaluating facilities.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Woodridge Nursing & Rehabilitation from 2025-03-13 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.