Avoiding IJs and Lawsuits- Part 2

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Good morning.

A couple of weeks back, we discussed the top high-scope and severity deficiencies cited so far in 2025. Number two on that list was F600—abuse and neglect—largely due to issues surrounding the initiation or omission of CPR inappropriately. These incidents often stem from confusion or miscommunication about residents' code statuses, leading to either the wrongful initiation of CPR on Do Not Resuscitate (DNR) residents or the failure to perform CPR on Full Code residents. Whether you're running a SNF, AL, or combination of the two, digging into this process is a must to reduce your regulatory and legal risks.

If you missed the article, you can check it out here. And if you haven't signed up for Assisto yet, do so here. There's no better way to reduce your regulatory risk and understand what surveyors in your state are honed into.

Elevate your Safety and Compliance

To prevent such critical errors and the severe consequences they entail, it's imperative to implement a robust CPR and code status compliance protocol. In studying the cited deficiencies there are two trends that emerge. First, employees did not know where to find the residents code status and started CPR without checking. Second, the community had a process that included a "sign" of code status (colored chart, wristband that states DNR, etc.) that didn't match the actual code status order.

Below are actionable steps your community can take to ensure clarity and compliance:

CPR & Code Status Compliance Protocol

1. Monthly Code Status Drills (All 3 Shifts)

First Drill of the Month: Conduct a tabletop scenario involving interdisciplinary staff to discuss procedures.
Remaining Drills: Execute live simulations, such as a "resident found unresponsive" scenario.

Drill Requirements:

Walk through the call process, staff roles, verification of code status, and response actions.
Simulate scenarios for both Full Code and DNR residents.
Conduct a debrief post-drill and document participation, successes, and areas for improvement.

2. Comprehensive Staff Education

Train all employees, including nursing, housekeeping, dietary, and administrative staff, on:

Who to call and how (e.g., activate emergency system, notify charge nurse, call 911 if appropriate).
Who assumes responsibility during a code situation.
The risks associated with initiating CPR on a DNR resident or delaying CPR on a Full Code resident.

Train licensed staff on:

Locating official code status in the physician order or MOLST/POLST form.
Understanding why visual cues like stickers or wristbands are unreliable and non-compliant.
Proper handoff and documentation protocols regarding code status.

3. Establish a Single Source of Truth

Eliminate unreliable visual cues (e.g., wristbands, color dots, paper chart stickers).
Ensure the only valid sources for code status are:
- A signed Physician Order (electronic or written).
- A completed MOLST/POLST form, as per state law.

Every staff member should confidently answer:

"Where do you find a resident’s code status?"
- Answer: "The order or MOLST. Period."

4. Quarterly Social Work Chart Audits

Verify that every resident has a documented code status via order or MOLST.
For residents lacking decision-making capacity, confirm:
- Valid certifications of incapacity are on file per state law.
- The code status order is signed by the authorized representative.
Audit for alignment between advance directives, legal decision-maker documentation, and the actual code status order.

5. Monthly Spot Checks & Staff Interviews

Randomly select 5–10 residents each month and interview staff across various departments and shifts:
- "What is this resident’s code status?"
- "Where do you find that information?"
- "What do you do if you find them unresponsive?"
Document and trend results via QAPI.
If less than 90% of staff answer correctly, initiate targeted retraining by shift or department.

6. QAPI Reporting and Escalation

Include in monthly QAPI:
- Drill participation logs.
- Spot check results.
- Chart audit outcomes.
- Identified inconsistencies or risks.
Accountability:
- Director of Nursing oversees nursing/clinical compliance.
- Social Work ensures order validity and legal alignment.
- Administrator/QAA monitors implementation and systemic issues.
If trends of noncompliance emerge, initiate:
- Targeted re-education.
- Competency testing.
- Follow-up audits at 30 and 60 days.

Implementing these steps diligently can significantly reduce the risk of F600 citations related to CPR and code status errors. It's about ensuring every team member understands their role and the importance of adhering to established protocols to protect our residents' rights and well-being.

Stay committed and proactive.

Partners We Love

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Kevin Goedeke, Publisher and Founder