Massachusetts Board of Registration in Nursing

Advisory Ruling on Nursing Practice

Title: Cardiopulmonary Resuscitation in Long-term Care Facilities

Advisory Ruling Number: 0801

The Massachusetts Board of Registration in Nursing (Board) is created and authorized by Massachusetts General Laws (M.G.L.) c. 13, §§ 13, 14, 14A, 15 and 15D, and G.L. c. 112, §§ 74 through 81C to protect the health, safety, and welfare of the citizens of the Commonwealth through the regulation of nursing practice and education.  In addition, M.G.L. c.30A, § 8 authorizes the Board to make advisory rulings with respect to the applicability to any person, property or state of facts of any statute or regulation enforced or administered by the Board.  Each nurse is required to practice in accordance with accepted standards of practice and is responsible and accountable for his or her nursing judgments, actions, and competency.  The Board’s regulation at 244 CMR 9.03(6) requires all nurses to comply with any other law and regulation related to licensure and practice.

Date Issued:  January 9, 2008

Date Revised: March 13, 2013, June 8, 2016

Scope of Practice: Registered Nurses and Licensed Practical Nurses

Purpose: To guide the decision-making of the nurse regarding cardiopulmonary resuscitation (CPR) when a patient or resident (patient) in a long-term care facility[1] with 24-hour skilled nursing staff on duty has experienced a cardiac arrest. 


Standard of Nursing Practice

The nurse licensed by the Board is expected to engage in the practice of nursing in accordance with accepted standards of practice.  It is the Board’s position that these standards, in the context of practice in a Massachusetts long-term care facility with 24-hour skilled nursing staff on duty, require initiating CPR when a patient has experienced a cardiac arrest.  In the event of an unwitnessed patient cardiac arrest, the nurse is expected to conduct an immediate sequential assessment of the patient and initiate CPR without delay, except when:

  1. The patient has a current, valid DNR order; or
  2. The body condition clearly indicates signs of irreversible death (e.g., decapitation, decomposition, transection, dependent lividity, rigor mortis); and
  3. The patient assessment confirms ALL of the following clinical signs[2] are present:
    1. Responsiveness:  No response;
    2. Respiratory Status:  No respirations for at least 30 seconds (the use of pulse oximetry is not appropriate for this assessment);
    3. Cardiac Status:  No pulse for at least 30 seconds by carotid artery palpation or apical auscultation;
    4. Pupillary Response:  Dilated bilateral pupils (if assessable), unresponsive to bright light; or
  4. A situation exists where attempts to perform CPR would place the rescuer at risk of serious injury or mortal peril

Nursing Documentation

The nurse must make complete, accurate and legible entries in all appropriate patient records required by federal and state laws and regulations, and accepted standards of practice. To demonstrate that the nurse has adhered to the accepted standard of nursing practice in not initiating CPR, documentation that substantiates the nurse’s determination of irreversible death must include:

  • Patient DNR status (e.g., directive for full resuscitation efforts, specified limited resuscitation efforts, DNR)
  • Findings from the nurse’s sequential patient assessment including: 
    • signs of irreversible death (e.g., decapitation, decomposition, transection, dependent lividity, rigor mortis)
    • responsiveness
    • respiratory status
    • cardiac status
    • pupillary responsiveness
  • Judgments and interventions made by the nurse based on sequential assessment of the patient including the decision not to initiate CPR
  • Collaboration and communication with other health care providers to ensure quality and continuity of care including dates and times of notifications of primary care providers
  • Collaboration and communication with the patient’s family or significant others including dates and times of notification

Nursing Competency Related to Advisory Ruling (AR)

Nurses are responsible and accountable for their nursing judgments, actions and competency with regard to performing CPR in accordance with accepted standards of practice. 

For the purpose of this Advisory Ruling, the licensed nurse must, at a minimum, attain and maintain the following competencies through successful completion of entry-level nursing education programs or continuing education experiences developed in accordance with Board regulations at 244 CMR 5.00: Continuing Education:

  • Signs and symptoms of cardiac arrest
  • Basic anatomy and physiology, including, but not limited to:
    • differentiating between dependent lividity and cyanosis
    • recognizing that pulse oximetry (SpO2, Peripheral oxygen saturation) should never be used for respiratory assessment following cardiac arrest
  • Standards of nursing practice, including, but not limited to current science and treatment recommendations from the American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation and Emergency Care for:
    • Basic Life Support for Healthcare Providers
    • Automated External Defibrillation (AED)
    • Criteria for Not Starting CPR
  • Documentation practices consistent with accepted standards of nursing practice
  • Knowledge of patient autonomy principles including:
    • resuscitation directives and verification of status
    • patient right to request or refuse CPR
    • informed consent based on the patient's receipt and understanding of accurate information about his or her condition, prognosis, proposed interventions, and the risks and benefits of alternatives such as CPR in the event of an unwitnessed cardiac arrest
  • Principles of patient teaching/learning including:
    • cultural and religious influences on patient's decision-making related to resuscitation directives
    • patient mechanisms for coping with life transitions
    • therapeutic communication
  • Ethical issues related to resuscitation directives including not initiating CPR
  • Clinical judgment and decision making skills related to initiating CPR during and after cardiac arrest
  • Problem solving, prioritization, and delegation skills
  • Role in obtaining accurate information about the DNR status of all assigned patients
  • Related statutes and regulations that pertain to this AR including those related to RN pronouncement and the definition of LTC
  • Policy(ies) established by the employing organization relative to resuscitation directives and withholding CPR

Nursing Management in the Long-term Care Setting 

The nurse in a nursing management role in the long-term care setting with 24-hour skilled nursing staff on duty is expected to adhere to accepted standards of practice for that role including development and implementation of necessary measures to promote and manage the delivery of safe nursing care.  Examples of such measures related to CPR include, but are not limited to:

  • Providing staff at all times who have maintained current CPR certification for healthcare providers through CPR training that includes hands-on practice and in-person skills assessment;[3]
  • Providing opportunities for licensed nursing staff to acquire and maintain competencies  related to facility policies and standards of care for CPR that will be completed, at a minimum, through new employee orientation, novice nurse transition and mandatory annual continuing education programs that include:
    • assessment of the signs of irreversible death;
    • resuscitation directives;
    • performance of CPR and AED use;
  • Standardizing hand-off communication including the patient’s current resuscitation status;
  • Incorporating unit-level nursing staff in evaluating clinical policies and procedures related the signs of irreversible death, resuscitation directives, documentation practices, CPR, and AED use;
  • Ensuring patient identification mechanisms are easily accessible to all direct-care nursing staff at all times and for all patients;
  • Ensuring that information about each patient’s resuscitation directive is readily accessible to all direct-care nursing staff; and
  • Adopting strategies for regular nursing practice audits to verify nursing competency and ongoing compliance with standards of care related to assessing irreversible death, resuscitation directives, documentation practices, CPR, and AED use.

Pronouncement of Death

The nurse’s decision to withhold initiation of CPR based on a sequential assessment is separate and distinct from the pronouncement of death.  Pronouncement of death for the purpose of allowing removal of the decedent’s body is governed by Massachusetts General Law, Chapter 46, Section 9.

Application of Advisory Ruling

This advisory is only applicable to the nurse who practices in a Massachusetts long-term care setting (with or without a sub-acute skilled care component) with 24-hour skilled nursing staff on duty.  While some of the underlying principles may be the same, it is not intended for application, in whole or in part, to the practice of nursing in any other setting at this time. 


2015 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

2015 Massachusetts Emergency Medical Services Pre-Hospital Treatment Protocols


[1] As defined at regulation 105 CMR 150.001 “Long-Term Care Facility shall mean any institution whether conducted for charity or profit which is advertised, announced or maintained for the express or implied purpose of providing three or more individuals admitted thereto with long-term resident, nursing, convalescent or rehabilitative care; supervision and care incident to old age for ambulatory persons; or retirement home care for elderly persons. Long-term care facility shall include convalescent or nursing homes, rest homes, infirmaries maintained in towns and charitable homes for the aged.”




This information is provided by the Division of Health Professions Licensure within the Department of Public Health.