Failure to Provide Effective CPR Due to Missing Equipment and Staff Incompetency
Penalty
Summary
The facility failed to provide effective cardiopulmonary resuscitation (CPR) to a resident who was identified as a full code, resulting in a delay of up to nine minutes before rescue breaths and oxygen could be administered. When the resident stopped breathing and had no pulse, the DON initiated chest compressions, but no rescue breaths were given initially because the Ambu bag mask was missing from the crash cart. Staff searched for the necessary equipment, with one LPN retrieving the mask from the nurse's desk and another attempting to set up the oxygen tank but unable to locate the key immediately. The oxygen was eventually connected, but only after a delay due to the missing mask and difficulty finding the key. During the code, staff also attempted to use the suction machine to clear the resident's airway, as the resident had significant secretions and a history of dysphagia and aphasia. However, staff were not knowledgeable about operating the suction machine, and it was never successfully used on the resident. The crash cart checklist had been marked as complete, but the required mask was not present at the time of the emergency, indicating a failure in equipment checks and readiness. The AHA guidelines and facility policy required rescue breaths and suctioning as part of CPR, but these were not provided in a timely manner due to missing supplies and lack of staff competency with the equipment. Additionally, when EMS arrived, staff stopped CPR before EMS personnel were ready to take over, resulting in a lapse in compressions. EMS had to ask if CPR was still needed and then resumed compressions upon entering the room. The resident, who had severe cognitive impairment and multiple medical diagnoses including sepsis and pressure ulcers, ultimately expired. The deficiency was identified through observation, interviews, and record review, and was determined to be at the immediate jeopardy level due to the failures in emergency response, equipment availability, and staff competency.