Failure to Maintain AED Results in Nonfunctional Equipment During Cardiac Emergency
Penalty
Summary
The facility failed to ensure timely checks and maintenance of its medical equipment, specifically the Automated External Defibrillator (AED). According to interviews and record reviews, the AED was not checked daily as required, and the last documented check occurred at the end of June. On the day of the incident, when a resident returned from the hospital with a diagnosis of acute respiratory failure with hypoxia, the resident experienced an episode of not breathing and became unresponsive. Staff followed protocol by moving the resident to his room, placing him on the bed with a cardiac board, and retrieving the code cart and equipment. During the emergency response, the RN attempted to use the AED on the resident, but the device would not function. The RN was unsure if the battery was dead or if there was another issue. As a result, staff proceeded with chest compressions and used an Ambu bag while waiting for EMS to arrive. EMS took over upon arrival, but the resident was pronounced dead after 20 minutes of resuscitation efforts. The facility's policy required daily checks and maintenance of the AED, but this was not followed, leading to the equipment being nonfunctional during a critical event.