AAPACN is dedicated to supporting post-acute care nurses provide quality care.

How the DNS Can Ensure Staff Preparation for Code Situations

A certified nursing assistant (CNA) conducting afternoon rounds finds Mr. Smith slumped over in his chair. The CNA notices that he does not appear to be breathing and calls the nurse for help. The nurse enters Mr. Smith’s room and checks for a pulse and respirations. Finding neither, the nurse calls a code. Staff arrive with the code cart, but things seem to unravel from there. Individual staff members do not know what each of their roles should be during the code, and necessary items are missing from the crash cart, which sends multiple staff in different directions to obtain them. Furthermore, it emerges that none of the staff present have a current cardiopulmonary resuscitation (CPR) certification. Paramedics arrive at a chaotic scene. They take charge and transport Mr. Smith to the hospital, leaving the staff to wonder what in the world just happened and how they keep it from happening again.

While code situations can be stressful, a lack of preparation exacerbates confusion, can create chaos, and could also risk the loss of a resident’s life. This article will provide the director of nursing services (DNS) with ways to ensure staff are prepared for a code.

Federal Requirements.

According to F678 in Appendix PP – Guidance to Surveyors for Long Term Care Facilities of the State Operations Manual, facilities must:

Provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident’s advance directives. (CMS, 2023).

When a facility does not provide life support as it should have, it can face several regulatory citations, including:

  • F600 Freedom from Abuse, Neglect, and Exploitation
  • F658 Services Provided Meet Professional Standards
  • F659 Qualified Persons
  • F684 Quality of Care
  • F726 Competent Nursing Staff

These citations can have a scope and severity up to immediate jeopardy, leading to enforcement remedies.

Advance Directives and Code Status

To provide basic life support consistent with the resident’s advance directives, facility staff must know what type of medical treatment the resident (or his or her representative) wishes for their care. Such wishes, including code status, can be found in a resident’s advance directives. The Centers for Medicare & Medicaid Services (CMS) defines advance directives in F-tag 678 as “a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated.” (CMS, 2023)

The most common types of advance directives include:

  • Living will
  • Durable power of attorney for healthcare/medical power of attorney
  • Physician Orders for Life-Sustaining Treatment (POLST)
  • Do Not Resuscitate physician orders (National Institute on Aging, 2022)

For residents who already have one or more of these signed documents, the documents should be part of the medical records. If they do not, a staff member, such as a social services member, should discuss with the residents or their representatives what their wishes are and proceed accordingly.

A resident’s code status should always be clearly marked in the medical record so staff can access it quickly during an emergency. Time is of the essence in medical emergencies, and staff cannot afford to spend that time searching through the medical record to determine the resident’s code status. In the absence of advance directives containing clear guidance on the resident’s code status, staff must perform CPR. Conversely, performing CPR on a patient who has rejected it may expose the facility to legal liability or additional citations. A clear understanding of residents’ instructions, quickly retrievable during a code, is essential to respecting residents’ wishes for their own care.

Crash cart

The crash cart is a vital tool for providing life support during a code. Its intent is to ensure that the equipment and supplies necessary to manage a medical emergency are available and quickly accessible. Nursing leadership must ensure that each crash cart is ready for the next medical emergency. Problems with crash carts could delay life-saving care. The Joint Commission, in the 2017 Quick Safety newsletter, Issue 32, listed numerous problems observed with crash carts, including:

• Medication errors and mix-ups

• Missing, expired, damaged, contaminated, and unavailable equipment or medications

• Empty oxygen tanks

• Drained batteries on equipment or equipment failure

• Unsecured carts or carts that have been tampered with

• Carts secured with heavy duty tape and/or padlocks, preventing immediate access

• Incorrect size of equipment

• Carts not checked or inspected according to policy and procedure

• Staff unable to locate the crash cart, resulting in a delay getting emergency equipment to the bedside

• Staff unfamiliar with the crash cart’s contents

• Staff unfamiliar with procedures for using the crash cart when responding to a life-threatening emergency

• Staff unfamiliar with procedures regarding how to stock or restock the crash cart (The Joint Commission, 2017)

All crash carts should have an in-depth audit completed at least monthly and following each use in an emergency. In addition, performing an abbreviated audit of crash carts daily ensures that they are always ready for use. AAPACN has developed an Emergency Crash Cart Checklist and Crash Cart Daily Signature Log to assist with these comprehensive audits and daily checks.

Policies and Procedures

F678 requires a facility to have a policy and procedure in place to ensure there is always an adequate number of staff present in the facility who are certified in CPR. Additionally, the facility policy should include:

  • Documentation of resident’s choices regarding CPR
  • Obtaining physician’s orders regarding choices after admission, upon a change in resident choice or condition
  • Communication of resident’s choice to facility staff
  • Documentation
  • CPR certification for staff

The facility should review its policy and procedure on an annual basis to ensure it is up to date and complies with state and federal requirements. If the review prompts any changes, communicate them to staff promptly.

Analysis of Events

When a code occurs, it is important that the QAA/QAPI Committee review each occurrence to determine what went right and what did not. If there were issues, drill down to find the root causes of the issue. The factors most often contributing to errors are staff’s lack of knowledge and training to perform in a code situation, problems with crash cart contents, and confusing or inaccessible documentation of code status. Once issues have been identified, implement corrective action as soon as possible to prevent the error from re-occurring. Following corrective action implementation, conduct several mock codes. Drill different staff using different scenarios to ensure the corrective action has eliminated the error and not created any new problems.

Staff Training

It is imperative that staff know how to respond when a code occurs. Nursing leadership should train staff upon hire, annually, and as needed. Training can take multiple forms, including lecture, reading, and mock drills, to ensure staff knowledge regarding medical emergencies. Ensure that these trainings include, at a minimum, content on:

  • Resident code status and identification
  • Crash cart maintenance
  • Roles during a code
  • Documentation
  • Notification
  • Use of an automated external defibrillator (AED)
  • CPR
  • Facility policy and procedures for CPR emergency management

Although mock drills require planning, they are great learning opportunities, as they immerse staff members into the scenario and enable them to practice their responses. Perfecting one’s reactions to an emergent event that is hypothetical strengthens responses during real-world emergencies. Once the drill is complete, the DNS should analyze the event and debrief the participants on both individual performance and team collaboration. Consider what went well and what was less than ideal. Were any resources lacking, or did gaps in knowledge or process emerge? How can the facility improve? AAPACN developed the Emergency Drills: Code and Elopement Toolkit to assist with drill planning and evaluation.

CNAs also need training to help them understand the basic actions to follow during a code. DNSs can utilize AAPACN’s Basics of Emergency Care for Medical Emergencies – Nursing Assistant In-Service Education to help train and prepare CNAs on how to respond during a code and other medical emergencies.

While codes can be extremely stressful situations, with preparation, the facility can respond effectively. Equipping staff with proper planning, resources, and training will empower them to execute under pressure.


Centers for Medicare & Medicaid Services. (2023). State Operations Manual, Appendix PP – Guidance to surveyors for long term care facilities. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf

The Joint Commission. (2017). Crash-cart preparedness. Quick Safety, Issue 32, 1. https://www.jointcommission.org/-/media/tjc/documents/newsletters/quick_safety_issue_32_20171pdf.pdf

National Institute on Aging. (2022). Advance care planning: Advance directives for health care. https://www.nia.nih.gov/health/advance-care-planning-advance-directives-health-care

For permission to use or reproduce this article in full or in part, please complete a permissions form