Resident Dies When Staff Fail to Perform CPR At Fair Oaks Rehab & Healthcare

The Illinois Department of Health has cited and fined Fair Oaks Rehab & Healthcare when a nurse discovered a resident without vital signs and failed to initiate cardiopulmonary resuscitation (CPR), despite the resident being designated as “full code.” Emergency responders who arrived approximately 40 minutes after the resident was found unresponsive were the first to perform CPR, by which time it was too late to save the resident’s life.

The incident involved a female resident whose care plan clearly documented that she was a “FULL CODE” with instructions to “Ensure resident’s wishes are honored in regard to any advanced directive.” According to facility records, a Registered Nurse (RN) entered the resident’s room around 5:40 PM to check on her and found she had “no bp (blood pressure), no pulse, no respiration.” The nurse noted the resident was “cold to touch” with “mottling on left side of body.”

Rather than immediately initiating CPR as required for full-code residents, the nurse called for another nurse to verify the absence of vital signs, then contacted the Manager on Duty (MOD) to report the resident “had passed away.” When asked by the MOD if the resident was on hospice, the nurse replied, “No, she was a full code.” The MOD immediately instructed the nurse to “get off the phone and initiated compressions and have someone call 911,” but the nurse refused, stating, “No, she is already mottled and dead, I’m calling [the Director of Nursing].”

The Director of Nursing (DON) reported receiving a call from the nurse at 5:49 PM, during which the nurse informed her the resident “had passed away.” When the DON asked about the resident’s code status, the nurse had to check before confirming she was a full code. The DON stated she “told her that she should have started CPR right away, and needed to start a code.” When the DON called back to check if CPR had been initiated, the nurse admitted she had not started CPR, insisting, “She’s gone, it looks like she has been gone for a little while.”

Multiple staff members confirmed that no CPR was performed by facility staff at any point. A Certified Nursing Assistant (CNA) reported that after the nurse discovered the resident without vital signs, the nurse told her the resident “had passed away and she needed to clean her up.” The CNA proceeded to provide incontinence care to the resident while waiting for emergency services. Another nurse who had verified the absence of vital signs heard the first nurse say, “Oh my God, this patient is a full code,” followed by, “I am not doing CPR, I am calling 911.”

The local Fire Department was not called until 6:06 PM—approximately 26 minutes after the resident was found unresponsive—and arrived at the scene at 6:22 PM. According to the Deputy Chief, “the resident’s face was pale, lips were pink and her core and arms were still warm to touch,” suggesting the resident had not been deceased for long. Emergency responders immediately initiated CPR after confirming the resident was a full code. The Fire Department’s narrative specifically noted that “no one was performing CPR upon their arrival and that their CPR was the first CPR initiated.”

A Nurse Practitioner interviewed during the investigation expressed surprise at the resident’s death, stating she “had just seen the resident a few days prior and she was doing ok.” The Nurse Practitioner emphasized that mottling “does not always mean that they are deceased” and “can have mottling for various reasons including hypoxia, change in heart rhythm, or change in vitals.” She insisted that “a code is still warranted even if the resident has mottling present.”

Following this incident, the facility was cited for Immediate Jeopardy—the most serious level of violation.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.