The Illinois Department of Health has cited and fined Bethany Rehab & Healthcare Center when staff failed to initiate cardiopulmonary resuscitation (CPR) on a full-code resident who stopped breathing after choking on food. The delay in resuscitation efforts continued until emergency responders arrived approximately eight minutes later, despite facility policy requiring immediate CPR for residents designated as “full code.”
The incident involved a female resident who had been identified as having difficulty swallowing related to facial pain from burn wounds. According to nursing notes, the resident had been “sleeping on and off” throughout the day and had eaten only “25% of her lunch.” During an evening family visit, a family member alerted a Licensed Practical Nurse (LPN) that the resident was choking. The nurse entered the room to find family members attempting to position the resident upright while food was visible “in and around her mouth.”
The nurse reported that he cleaned food from the resident’s mouth and heard “gurgling” sounds, which led him to believe she had aspirated food. He decided to call 911, leaving the room to make the call. While the nurse was calling 911, a family member approached him at approximately 5:35 PM, making a hand gesture across his neck and stating the resident had “stopped breathing.” Although the nurse claimed he “rushed for the crash cart,” he admitted he did not initiate CPR before paramedics arrived at 5:41 PM – approximately six minutes after being informed the resident had stopped breathing.
Multiple staff accounts confirmed that no CPR was performed prior to paramedics’ arrival. A Registered Nurse stated she was called by the LPN “to verify a resident’s death” before paramedics arrived and found the resident with “no heart rate, no respirations.” She assumed the resident was DNR (Do Not Resuscitate) because “V4 did not call a code or initiate CPR.” Another Certified Nursing Assistant confirmed that “CPR was not started until the paramedics arrived.”
The paramedic who responded to the call reported that when he arrived at the facility, he was initially told by the male nurse that the resident “had passed away.” Upon entering the resident’s room, he found no staff members present, only family, and “CPR was not being performed.” When he inquired about the resident’s code status and learned she was “full code,” he informed the family that CPR would need to be initiated. Despite the son’s objection, the paramedic explained that “according to protocol, CPR must be initiated because the resident was a full code, and none of the family members were her POA (Power of Attorney).” Paramedics finally began CPR at 5:43 PM – approximately eight minutes after staff were notified the resident had stopped breathing.
Both the facility’s on-call nurse and Medical Director confirmed that CPR should have been started immediately upon determining the resident had no pulse or respirations. The Medical Director emphasized, “You must start CPR immediately to achieve the best outcome. Ten minutes is way too long to wait and could definitely affect the outcome of a resident.” The paramedic similarly stated, “Six to ten minutes is a long time to wait to start CPR. There would be no blood return to the brain and brain death/cell death occurs.”
The facility’s own policy explicitly states that “the chances of surviving sudden cardiac arrest may be increased if CPR is initiated immediately upon collapse.” Multiple facility records, including the Transfer/Discharge Report and Order Summary Report, confirmed the resident was designated as “Full Code,” meaning life-saving measures were required.
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