Failure to Retrieve and Use AED During Code Blue Response
Penalty
Summary
A deficiency occurred when a resident, who was a full code and had a significant cardiac history including atrial fibrillation, cardiac pacemaker, hypertension, coronary artery disease, unstable angina, and recent cardiac effusion, was found unresponsive and pulseless during the evening shift. The certified nurse aide discovered the resident and immediately notified the nurse, who assessed the resident, called a Code Blue, obtained the crash cart, and began CPR. Another nurse called 911 and assisted with CPR until EMS arrived. Despite the facility's policy requiring immediate retrieval and use of the Automated External Defibrillator (AED) during a Code Blue, the nursing staff did not obtain or apply the AED at any point during the resuscitation efforts. Interviews with the involved staff confirmed that no one was directed to retrieve the AED, and the device was not present in the room when EMS arrived. The Director of Nursing and the Nurse Practitioner both stated that the AED should have been used according to facility policy and professional standards of nursing practice. Documentation and interviews further indicated that the staff were current on CPR certification and followed other aspects of the emergency response, such as calling 911 and performing CPR. However, the failure to obtain and use the AED during the Code Blue was a direct violation of the facility's emergency procedures and professional standards, as outlined in the facility's own policy.