Failure to Implement Emergency CPR Procedures and AED Use for Full Code Resident
Penalty
Summary
Facility staff failed to implement their policy and procedure for emergency response and cardiopulmonary resuscitation (CPR) for a resident with a full code status who was found unresponsive in bed. A Certified Nursing Assistant (CNA) observed the resident was not breathing but left the resident unattended to notify Registered Nurses (RNs) instead of activating the code blue system or initiating immediate life-saving measures. The CNA did not check the resident's vital signs or pulse upon finding the resident unresponsive and did not activate the code blue as required by facility policy. When the RNs and a Licensed Vocational Nurse (LVN) responded, they initiated CPR but did not utilize the facility's Automated External Defibrillator (AED), despite the policy requiring staff to be trained in its use. One RN admitted to not knowing how to use the AED and confirmed that staff had not been trained on its use during CPR. The staff also failed to check and document the resident's vital signs and blood sugar during the code, even though the resident had a history of diabetes and other significant medical conditions. The facility's policy required all clinical staff to be trained and certified in Basic Life Support (BLS)/CPR, including the use of defibrillation, and to follow a specific sequence of actions during a code blue. However, interviews and record reviews revealed that staff were not knowledgeable or adequately trained in these emergency procedures, resulting in the failure to provide timely and appropriate life-saving interventions for the resident. This deficiency was identified as having resulted in the resident's death and placed other residents with full code status at risk.