Failure to Provide Effective Basic Life Support and CPR
Penalty
Summary
Facility staff failed to provide effective basic life support, including CPR, to two residents who experienced cardiac arrest on weekends. In both cases, staff did not ensure that chest compressions were performed on a hard surface, as required by American Heart Association guidelines, and did not consistently use an AMBU bag for ventilation. For one resident, there was a delay in locating the AMBU bag, and staff were unable to find the resident's code status promptly in the electronic medical record, leading to further delays in initiating appropriate resuscitation efforts. Additionally, staff did not know how to use the intercom system to announce a Code Blue, which hindered the ability to quickly summon additional help. The first resident had a history of heart failure, chronic atrial fibrillation, diabetes, chronic obstructive pulmonary disease, and prior respiratory failure. This resident was found unresponsive with no pulse or breathing, and although staff attempted CPR, they did not use a backboard or hard surface, and there was confusion and delay in using the AMBU bag for ventilation. Emergency responders reported that when they arrived, staff were either about to start or had just started CPR, but no crash carts or AMBU bag were in use, and no backboard was present. The resident was a full code, but the code status was not immediately accessible in the electronic record, and staff were unfamiliar with the process for overhead Code Blue announcements. The second resident, who had multiple chronic conditions and was a full code, was found unresponsive and without vital signs. Staff initiated chest compressions but did not move the resident to a hard surface or use a rigid backboard. An AMBU bag was eventually connected for ventilation, but only after additional staff arrived with the crash cart. There was no overhead Code Blue announcement, and communication among staff was disorganized, with delays in calling 911 and confirming code status. In both cases, EMS arrived and took over resuscitation efforts, but both residents expired. Observations after the incidents confirmed that crash carts were equipped with necessary equipment, including backboards and AMBU bags, but these were not utilized effectively during the emergencies.