In late February of this year, an employee at an independent living facility in Bakersfield, California was asked by a 911 dispatcher to begin CPR on an 87-year-old resident.  Despite the 911 dispatcher’s pleas, the employee refused.  The employee was allegedly following a facility policy that, in the event of a health emergency, the staff is to immediately call EMS for assistance and wait with the resident. The residents are informed of and agree to this policy on admission. The resident ultimately passed away.  Although the resident’s family expressed satisfaction with the manner in which the facility handled the situation, the situation generated a great deal of negative publicity. This situation also caused many assisted living facilities (“ALFs”) to question whether they are required to provide CPR. Unlike skilled nursing facilities, ALFs provide a lower level of care to their residents and often do not have nursing personnel on staff 24-hours per day.

The answer to the question of whether an ALF can have a policy like the one at issue in the California situation depends largely on state law.  At least 18 states have explicit laws requiring CPR-trained staff members in ALFs.  Oregon recommends CPR training, but does not require it.  Montana law provides that CPR-trained staff need only be on duty if the facility offers CPR, impliedly authorizing a “no-CPR” policy.  Kentucky is similar but more explicit:  ALFs must train staff on CPR “unless the policies of the [ALF] state that this procedure is not initiated by its staff….” 

In Missouri, like many states, the law is unclear. While there is no requirement that staff be CPR-trained, ALFs are required to provide 24-hour “protective oversight.”  19 CSR 30-86.047(35).  At least one Missouri ALF has been cited for failure to provide protective oversight by failing to attempt CPR on a resident.  However, this facility also had a policy stating that it would have CPR-trained staff and provide CPR to residents unless they had a DNR.  In Kansas, the April 2013 KDADS newsletter confirmed that there is no requirement for CPR-trained staff, and because residents may have an expectation that CPR will be performed, each adult care home should disclose, prior to admission, its process for responding to individuals who desire CPR.  See KDADS, Sunflower Connection, Vol. 10, No. 2 (April 2013).

There are several justifications for having a “No-CPR” policy or a policy where CPR will not be routinely performed in states that permit ALFs to decide one way or the other.  Besides the staffing issue, attempted CPR can also cause harm to elderly residents, including broken ribs, sternum fractures, and dislodged pacemaker electrodes.  Additionally, attempted CPR on the elderly has very low success rates.  See Steven C. Zweig, Cardiopulmonary Resuscitation and Do-Not-Resuscitate Orders in the Nursing Home, 6 Arch. Fam. Med. 424, 426 (1997) (citations omitted) (the author evaluated numerous studies which showed survival rates ranged from 0-5%); see also CDC, Out-of-Hospital Cardiac Arrest Surveillance — Cardiac Arrest Registry to Enhance Survival (CARES), United States, October 1, 2005–December 31, 2010 (July 29, 2011), available at (showing a survival rate of 3.7% for cardiac arrests occurring in nursing homes and ALFs and a survival rate of 9.3% for cardiac arrests in those aged 65-79 and 4.6% for those aged 80 and over).

Our Insight.  Your Advantage.  As always, regardless of what state law provides, ALFs should consider the potential for civil actions when evaluating policies.  And, regardless of the policy selected, disclosure and education are key.

To access my PowerPoint slides from a recent presentation on this topic, click here:

To Code or Not to Code: That’s Not Really the Question