Failure to Provide Effective CPR and Basic Life Support
Penalty
Summary
Facility staff failed to provide effective cardiopulmonary resuscitation (CPR) consistent with basic life support protocols to a resident who was found unresponsive, pulseless, and not breathing. The resident, who had a history of acute and chronic respiratory failure with hypoxia and a tracheostomy, was documented as a full code, indicating a desire for all life-saving measures, including CPR. Upon discovery, staff transferred the resident from the toilet to the bed and initiated CPR, with one staff member providing rescue breaths via Ambu bag and another performing chest compressions. An Automated External Defibrillator (AED) was also applied during the resuscitation attempt. Review of documentation and staff interviews revealed that CPR was performed on the bed without the use of a backboard, contrary to best practices for effective chest compressions on soft surfaces. The Director of Nursing Services (DNS) stated that staff should have moved the resident to the floor or used a backboard if CPR was performed on the bed. Additionally, the facility's policy required rescue breaths to be delivered at a rate of 10-12 breaths per minute via Ambu bag for residents with a tracheostomy, but staff interviews and emergency personnel reports indicated that rescue breaths were inconsistently provided, with one staff member admitting to delivering only three breaths per minute and delegating the task to an unidentified staff member at one point. Emergency personnel arrived to find staff performing only chest compressions, with no evidence that rescue breaths or supplemental oxygen were being administered at that time. The resident was subsequently transported to the hospital, where death was pronounced shortly after arrival. The facility was unable to provide evidence that effective CPR, consistent with basic life support protocols and facility policy, was provided throughout the resuscitation effort.