Saint John Paul II Center: Nurse Death Pronouncement - CT

The incident involved Resident #2, who was designated as a "full code" patient, meaning staff were required to attempt resuscitation if the person stopped breathing or their heart stopped beating.

When staff discovered Resident #2 unresponsive, not breathing, and without a pulse, two nurses immediately began CPR. But instead of calling 911 as required by facility policy, RN #2 made the decision to pronounce the resident dead after 20 to 30 minutes of resuscitation efforts.

The facility's medical director told inspectors that when a full code resident is found in that condition, "911 was called, and CPR is initiated." He emphasized that emergency medical services personnel should have been called to pronounce Resident #2's death, not facility staff.

"RN #2 should not have pronounced Resident #2's death," the medical director stated. He explained that the resident "did not have a physician's order that directed an RN pronouncement of death."

The sequence of events began when RN #2 discovered Resident #2 unresponsive and notified LPN #1. According to LPN #1's account to inspectors, she immediately rushed to the resident's room with RN #2 upon learning the situation.

"When she entered the room, Resident #2 was unresponsive, not breathing with an arm dropped down to the side and Resident #2 was blue," the inspection report states.

Both nurses immediately began CPR and continued the resuscitation efforts together for approximately 20 to 30 minutes. At that point, RN #2 left the room to make phone calls to the family and the on-call provider, while LPN #1 continued performing CPR alone until the family arrived.

The Director of Nursing confirmed to inspectors that the response violated established protocols. She stated that "when Resident #2 was found unresponsive and CPR was initiated, RN #2 should have called 911, so EMS could have pronounced Resident #2's death."

The nursing director emphasized that "RN #2 should not have pronounced Resident #2's death and RN #2 should have known that an RN pronouncement requires a physician's order."

Federal regulations require nursing homes to have specific authorization before registered nurses can pronounce death. Without a physician's order explicitly granting this authority, only emergency medical services personnel or physicians can make such pronouncements.

The facility's own cardiopulmonary resuscitation policy clearly outlined the proper procedure. According to the policy reviewed by inspectors, "if a patient does not have a do not resuscitate order (DNR), CPR certified staff will initiate CPR and emergency medical services (EMS) will be activated."

The policy also specified that "CPR should also be discontinued when a provider, including a nurse (RN) or nurse practitioner (NP) pronounces death provided they have the authority to do so."

In this case, RN #2 lacked the required authority to pronounce death, making the decision to stop resuscitation efforts and declare the resident deceased a violation of both facility policy and federal regulations.

The incident raises questions about staff training and understanding of emergency protocols at the 33 Lincoln Avenue facility. Both the medical director and Director of Nursing indicated that the proper procedure was well-established: call 911 immediately when a full code resident is found unresponsive, continue CPR until emergency medical services arrive, and allow EMS personnel to make the death pronouncement.

The medical director's expectation was clear: "911 should have been called so EMS personnel could have pronounced Resident #2's death."

Instead, the family arrived to find that facility staff had already declared their loved one dead and stopped resuscitation efforts, potentially cutting short life-saving measures that should have continued until emergency medical professionals could take over.

The violation was classified as causing "minimal harm or potential for actual harm" affecting "few" residents, according to the inspection report. However, the incident highlighted a fundamental breakdown in emergency response procedures that could affect any resident requiring resuscitation.

LPN #1's actions during the emergency appeared to follow protocol. She immediately responded when notified, began CPR promptly upon assessing the resident's condition, and continued resuscitation efforts even after RN #2 left the room. Her persistence in performing CPR until the family arrived demonstrated understanding of the requirement to continue life-saving measures.

The contrast between LPN #1's response and RN #2's decision to pronounce death without authorization underscored the confusion about proper emergency procedures among nursing staff.

Federal inspectors found that the facility failed to ensure proper emergency response protocols were followed when a full code resident required resuscitation. The investigation revealed that staff made critical decisions about life and death without following established procedures or obtaining required authorization.

The case illustrates the importance of clear emergency protocols and proper staff training in nursing homes, where split-second decisions during medical emergencies can mean the difference between life and death. When those protocols break down, families may be left wondering whether everything possible was done to save their loved one's life.

Resident #2's family arrived to find that resuscitation efforts had already been terminated by facility staff, rather than by emergency medical professionals trained to make such determinations. The decision to stop CPR and pronounce death rested with a nurse who lacked the legal authority to make that call.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Saint John Paul II Center from 2025-08-21 including all violations, facility responses, and corrective action plans.

Additional Resources

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