Failure to Maintain AED Functionality During Cardiac Emergency
Penalty
Summary
The facility failed to ensure the regular checking and maintenance of its automatic external defibrillator (AED), resulting in the device being inoperable during a critical cardiac arrest emergency involving a female resident with a history of heart disease, pulmonary embolism, and mediastinal cancer. When the resident was found unresponsive and a Code Blue was called, staff attempted to use the facility's AED, but it would not turn on due to a dead battery. There was no backup battery available at the time, and the staff had to rely on an AED provided by a first responder. Interviews and record reviews revealed that the AED was not included in the routine crash cart checklist, and there was no documentation of regular functionality checks or battery monitoring. The Director of Nursing and Maintenance Director both confirmed the absence of a process or evidence for AED checks, and the AED Inspection Log showed the last inspection was not recent. The lack of established procedures and documentation for AED maintenance directly led to the device's failure during the emergency.