F0908

E

Failure to Maintain AED and Crash Cart Supplies for CPR

Carmi, Illinois Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain essential emergency equipment on the crash cart, specifically the automated external defibrillator (AED), while it was present and expected to be available for use during cardiopulmonary resuscitation (CPR). One resident with multiple serious cardiopulmonary and systemic diagnoses, including acute and chronic respiratory failure with hypercapnia and hypoxia, pulmonary hypertension, obstructive sleep apnea, and chronic kidney disease, had a POLST form indicating full code status with orders to attempt CPR and use all indicated life-sustaining treatments, including intubation and mechanical ventilation. The resident was cognitively intact per a BIMS score of 15 and dependent on staff for activities of daily living.

On the day of the event, a physical therapist notified an LPN that the resident was unresponsive. The LPN entered the room, found the resident not breathing and without a pulse, and initiated CPR while 911 was called. Another LPN retrieved the crash cart, provided an Ambu bag to staff, and attempted to use the AED. When she opened the crash cart and the AED, she could not locate any AED pads on the cart and the AED repeatedly announced “low battery.” She reported that she ultimately closed the AED because there were no pads and the device was indicating a low battery, and she felt she had wasted time searching for pads and trying to hook up the AED. EMS arrived and the resident was later pronounced dead.

Interviews and record review showed that the facility had only one crash cart, and the ADON stated she was responsible for checking it monthly. The crash cart checklist did not include the AED, and there was no documentation that the AED was being checked as part of the crash cart inventory. The ADON stated that for approximately four months the AED had repeatedly given a “low battery” voice prompt when opened, and that she had informed the facility owner, who stated they did not need a new battery at that time. Staff reported that the last set of AED pads had been used during a prior code and that this had been reported to the ADON, but no replacement pads were available when the resident coded. The administrator acknowledged he had known about the low battery for some time and that ordering a battery and pads required an approval process, and invoices and supplier confirmations showed that the battery and pads were not ordered until after the later code event.

Additional interviews revealed that the regional director of operations was unaware an AED was in the facility and did not see a problem because he believed an AED was not required by regulation until a future year. The DON confirmed awareness that the AED on the crash cart had a low battery for at least a couple of months and that the last set of pads had been used in a prior code, leaving no adult pads available for the subsequent code. The facility owner stated he was aware of the low battery and asserted that the AED was still functioning, and he also stated that the nurses did not need to use the AED on the last code. Observation of the AED with the administrator present showed the device flashing red lights and repeatedly announcing “low battery” when opened. The AED manufacturer’s manual specified daily and monthly maintenance, including checking that the status indicator is green and replacing the battery when the indicator is red and flashing. Facility policies required that the emergency cart be inventoried and restocked after each use, checked at least monthly with documentation, and that equipment and supplies necessary for CPR/BLS be maintained in the facility at all times. At the time of the survey, 32 residents in the facility had active orders to attempt resuscitation/CPR.