Staff at Tracy Nursing and Rehabilitation Center did not initiate cardiopulmonary resuscitation for Resident 1, despite the patient's Full Code status requiring immediate emergency response. The resident's representative had signed legal documents directing the facility to provide all possible life-saving interventions.
The Director of Nursing confirmed during interviews that CPR had not been started for Resident 1. She acknowledged that facility policy was not followed by nursing staff and stated her expectation was that CPR should have been initiated immediately because the resident was Full Code.
"The decision to perform CPR was not up to the nursing staff," the Director of Nursing told inspectors. She explained that Resident 1's representative had already signed the POLST form indicating Full Code status, making resuscitation mandatory in emergency situations.
The facility's own policy requires staff to provide basic life support, including CPR, when there is no Do Not Resuscitate order in place. The written protocol specifically states that properly trained personnel must be available to provide cardiopulmonary resuscitation to those requiring emergency care.
According to facility procedures, staff should immediately initiate Code Blue emergency response in cardiopulmonary emergencies. The protocol requires concurrent emergency activities including assessing the individual, activating 911, positioning the person for CPR, initiating chest compressions, and retrieving the crash cart.
The Director of Nursing explained the standard process begins with calling Code Blue and taking the crash cart immediately to the resident's location while initiating CPR. Additional staff should document the emergency and call emergency medical services simultaneously.
She described chest compressions as continuing "until EMS arrives, patient begins moving, or consciousness is regained." The policy mandates this response for any resident without a valid Do Not Resuscitate order.
The Director of Nursing detailed how code status decisions are made upon admission. Nurses explain the options and review POLST forms with residents or their representatives to provide education before the decision is made and the legal document is signed.
She emphasized the critical nature of timing in resuscitation efforts. "The time of discovery and the amount of down time were critical factors," she told inspectors. She explained that CPR outcomes depend heavily on how quickly intervention begins after cardiac arrest.
The nursing director acknowledged risks involved in resuscitation decisions, explaining that CPR is a life-saving intervention but outcomes depend on downtime. She noted this could result in either not receiving life-saving care or receiving care that might lead to conditions the resident would not be comfortable with.
When residents are admitted to hospice care, hospice nurses review POLST forms with residents or representatives to inform them about their rights regarding resuscitation decisions. This ensures patients and families understand the implications of their choices about end-of-life care.
The facility's policy states that staff will provide basic life support "subject to accepted professional guidelines, advance directives, and physician orders." In this case, the advance directive clearly specified Full Code status requiring all resuscitation efforts.
The Director of Nursing confirmed the facility was aware of Resident 1's code status, as it represented the wishes and direction of the resident's representative. The Deputy of Patient Care Services also confirmed this was the representative's explicit instruction to avoid any hospitalization while still maintaining Full Code status.
Federal inspectors found the facility failed to follow its own emergency response procedures. The policy requires immediate chest compressions when pulse is absent, activation of emergency services, and coordinated response activities to maximize chances of successful resuscitation.
The violation demonstrates how administrative failures can directly impact patient care during medical emergencies. When staff don't follow established protocols for Full Code residents, families' explicit wishes for aggressive life-saving measures go unheeded at the most critical moments.
The inspection found minimal harm occurred, affecting few residents. However, the failure to provide requested emergency care represents a fundamental breakdown in following both family directives and facility policies designed to protect patients' rights to choose their level of medical intervention.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Tracy Nursing and Rehabilitation Center from 2025-11-12 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Tracy Nursing and Rehabilitation Center
- Browse all CA nursing home inspections