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LTC Regulatory Review – F678 – CPR Procedures

During the May Regulation Summation, F678 was reviewed along with the Quality of Life regulations. A portion of F678’s interpretative guidance led to several questions regarding CPR certification training and the requirement for hands-on education for health care providers.

F678 requires that nursing homes have sufficient personnel who are trained to provide basic life support services, including CPR to a resident who has identified they desire life saving measures in accordance with their advance directives. The interpretative guidance includes the requirement that life saving measures must be performed prior to emergency medical personnel arriving on site and in accordance with the physician’s orders. Here are a few important things to outline within the interpretative guidance:

  • The nursing home must have sufficient staff certified to provide CPR to residents who:
    • Identify they want to be a full code.
    • Have a physician’s order for full code status.
    • Their clinical condition warrants CPR.
    • The nursing home can determine the number and credentials of “sufficient staff”. Some providers may decide to just have nursing staff certified, while others have the entire staff certified. You want to take into consideration (and likely include in your facility assessment) your location and how long it may take emergency medical staff to arrive at your building. For example, some rural providers who rely on volunteer first responders may need more staff certified to avoid fatigue and reliance on a couple staff when there may be a prolonged emergency medical staff response time. Whereas urban providers may expect emergency medical staff to have a shorter response time.
    • The CPR certification must be in accordance with the American Heart Association guidelines, which are published every five years. At a minimum, this certification must include basic life support for healthcare providers.
    • The certification cannot be fully online training. There may be an online education component, but skills and competencies should be assessed in-person.
    • Your policy can include the following circumstances (which likely are few and far between) that CPR is not provided when a resident is a full code:
      • Obvious clinical signs of irreversible death such as rigor mortis, dependent lividity, decapitation, transection, or decomposition.
      • Initiating CPR could cause injury or peril to the rescuer.
      • The nursing home should have practices for promptly discussing the resident’s wishes for CPR upon admission. In the event that the resident’s wishes are not or cannot be discussed upon admission, the nursing home should have  procedures for staff to follow in lieu of a completed form and physician’s orders that are in accordance with State law. Most of the time this will be providing CPR if there is not an active DNR order in place. If you have a practice for following verbal wishes, this should be witnessed by two staff members, unless the State provides more specific requirements.
      • The nursing home policy cannot limit staff to only calling 911 when cardiac or respiratory arrest occurs. (Note this is not the case in Assisted Living.)
      • The nursing home also cannot have a building-wide “no CPR” policy as this interferes with the resident’s right to formulate an advance directive.
      • Basic Life Support for Health Care Provider CPR generally includes the use of a second rescuer to prevent fatigue. While the regulation states that the nursing home must have “sufficient” staff, this should be taken into consideration.

In order to assess compliance with this requirement, the nursing home should review current CPR certifications for staff within your nursing home. When a list is established of current CPR certified staff compare this with the schedule to ensure that there are sufficient CPR certified staff on duty 24 hours per day/7 days per week. You should also review your current CPR policy and procedure to ensure that the above requirements are met.

If you want to compare how this regulation relates to the resident’s right to formulate an advance directive you can refer to a previous regulatory review article on F578. Generally, F578 relates to the formulation of the advance directive while F678 relates to performing CPR when required.

Another important aspect to point out is when staff fail to perform CPR if the resident is a full code can result in an immediate jeopardy deficiency. It is very important that you routinely evaluate your compliance with this regulation.