Failure to Provide Qualified Emergency Response and CPR
Penalty
Summary
Facility staff failed to provide care by qualified persons according to a resident's written plan of care, specifically in the response to a full code resident who was found unresponsive. Multiple staff members, including CNAs, RNs, and LVNs, did not immediately initiate a code blue or begin CPR when the resident was discovered unresponsive. Instead, staff delayed action by first attempting to verify the resident's code status and searching for the POLST form, rather than starting life-saving measures as required by facility policy and professional standards. Interviews and record reviews confirmed that staff were unclear about the correct sequence of actions and did not follow established protocols for emergency response. When CPR was eventually initiated, staff did not place the resident on a firm, flat surface or use the available backboard, as required to ensure effective chest compressions. Instead, CPR was performed on the bed, and the backboard was not utilized. Additionally, staff failed to provide rescue breaths using the Ambu-bag, despite its availability, and instead left the resident on a non-rebreather mask, which is not appropriate during CPR. EMS personnel arriving at the scene observed that CPR was being performed incorrectly, with inconsistent and inadequate chest compressions, and had to move the resident to the floor to continue resuscitation efforts. Documentation and interviews revealed further deficiencies in staff knowledge and execution of CPR, including incorrect compression rates, lack of rescue breaths, and failure to use proper equipment. The facility's own policies, as well as American Heart Association guidelines, were not followed. As a result, the resident was pronounced deceased after prolonged and inadequate resuscitation efforts. The failure to provide qualified and timely emergency care placed all full code residents at risk of not receiving proper life-saving measures during a code blue event.