CMS Issues Memorandum Concerning CPR in Nursing Homes

CMS has issued S&C Memo 14-01-NH (click here for the full memorandum), “Cardiopulmonary Resuscitation (CPR) in Nursing Homes,” making the following three key points:

•         Initiation of CPR - Prior to the arrival of emergency medical services (EMS), nursing homes must provide basic life support, including initiation of CPR, to a resident who experiences cardiac arrest (cessation of respirations and/or pulse) in accordance with that resident’s advance directives or in the absence of advance directives or a Do Not Resuscitate (DNR) order. CPR-certified staff must be available at all times.
•         Facility CPR Policy –Some nursing homes have implemented facility-wide no CPR policies. Facilities must not establish and implement facility-wide no CPR policies.
•         Surveyor Implications - Surveyors should ascertain that facility policies related to emergency response require staff to initiate CPR as appropriate and that records do not reflect instances where CPR was not initiated by staff even though the resident requested CPR or had not formulated advance directives.

The memorandum reiterates the resident’s right to formulate an advance directive, emphasizing the requirement that skilled nursing facilities provide written information to residents about this and other rights at the time of admission.   While acknowledging that research shows that CPR is generally ineffective among elderly nursing facility residents, the memo also notes that trends in the nursing facility population including more younger residents, more individuals seeking short-term rehabilitation, and increasing ethnic and cultural diversity and underscores the need for effective, individualized, well-documented and consistently implemented policies and procedures for advance directives. 

In this context, CMS clarifies that nursing facilities are not permitted to implement facility-wide no-CPR policies, stating:

“Facility policy should specifically direct staff to initiate CPR when cardiac arrest occurs for residents who have requested CPR in their advance directives, who have not formulated an advance directive, who do not have a valid DNR order, or who do not show AHA signs of clinical death as defined in the AHA Guidelines for CPR and Emergency Cardiovascular Care (ECC). Additionally, facility policy should not limit staff to only calling 911 when cardiac arrest occurs. Prior to the arrival of EMS, nursing homes must provide basic life support, including initiation of CPR, to a resident who experiences cardiac arrest in accordance with that resident’s advance directives or in the absence of advance directives or a DNR order. CPR-certified staff must be available at all times to provide CPR when needed. Facilities must not establish and implement facility-wide no CPR policies for their residents as this does not comply with the resident’s right to formulate an advance directive under F155. The right to formulate an advance directive applies to each and every individual resident and facilities must inform residents of their option to formulate advance directives. Therefore, a facility-wide no CPR policy violates the right of residents to formulate an advance directive.”