F0684

G

Failure to Provide CPR and AED Use for Full-Code Resident Found Unresponsive

Camp Verde, Arizona Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide life‑saving measures, including CPR and use of an AED, to a resident with full code status who was found unresponsive. The resident had multiple medical and psychiatric diagnoses, including pneumonia due to pseudomonas, osteomyelitis, bacteremia, autistic disorder, bipolar disorder, mood disorder, epilepsy, and a need for assistance with personal care. An advance directive signed by the resident indicated he wanted CPR if his breathing and heart stopped, along with other life‑prolonging treatments. A physician order dated January 26, 2026, confirmed the resident’s status as full code and indicated CPR was to be provided.

In the days prior to the incident, the resident was documented as having behavioral issues, aggressive outbursts, and a fall from bed shortly after an OT evaluation, with staff noting he might not be appropriate for the facility due to the need for 1:1 care. The resident was also identified as a high fall risk and had a witnessed seizure lasting about 50 seconds on January 25, 2026, after which neurological checks were initiated and the DON and a provider were notified. On the morning of January 26, 2026, facility self‑report documentation indicated the resident received medications around 7:00 a.m., breakfast at 8:30 a.m., and was checked at 9:30 a.m., at which time he was reportedly well.

Around late morning, a CNA delivering lunch found the resident on the floor and notified the DON. Multiple accounts, including the police report, CNA, RN, and corporate clinical resource nurse interviews, and the 911 call transcript, consistently indicated that when staff found the resident unresponsive and not breathing, CPR was not being performed. The 911 operator twice asked if CPR was in progress, and the staff member replied that no one was doing CPR and stated the resident was deceased. The police report documented that upon arrival, officers found the resident on the floor, unresponsive, cold to the touch, with a small laceration on the back of the head and dried blood on the floor, and noted that rigor mortis had not yet set in. The report also described the fall mats as not in use as claimed and the bed as freshly made, suggesting inconsistencies with the account that the resident had fallen from bed.

The DON gave conflicting statements, at one point telling police that CPR was not initiated, and at another time stating she began life‑saving measures but believed the resident was beyond help and did not move him to a flat position on the floor. The corporate clinical resource nurse reported that the DON later said she performed a sternal rub, checked for a pulse, and attempted only two chest compressions before stopping because the chest felt “mushy.” Other staff present, including the CNA who discovered the resident and the RN who assessed him, stated they did not observe CPR being performed at any time. There was no documentation in the clinical record of CPR being initiated, no evidence that an AED was brought to or used in the room, and no documentation of the head laceration noted by police. Facility policy required that licensed staff certified in CPR/BLS initiate CPR for an unresponsive individual not breathing normally unless a DNR order existed or there were obvious signs of irreversible death, and that CPR and BLS, including AED use, be continued until emergency medical personnel arrived. These actions were not carried out for this full‑code resident.

The facility’s policy on documenting death required that all information pertaining to a resident’s death, including time of death and the name and title of the individual pronouncing death, be recorded in the nurse’s notes, and that the attending physician document the cause of death. The record contained an e‑MAR note indicating the resident was deceased and an MDS death in facility assessment, as well as a vital records form listing a time of death, but there was no contemporaneous nursing documentation of CPR attempts or detailed description of the circumstances of death consistent with policy. The combination of staff failure to initiate and maintain CPR and use an AED for a full‑code resident, conflicting staff accounts, lack of documentation of life‑saving measures, and discrepancies between the physical scene and staff descriptions formed the basis of the cited deficiency.