F0678

J

Failure to Provide Timely BLS/CPR and Appropriate Choking Response

Longview, Texas Survey Completed on 02-20-2026

Penalty

Fine: $122,590

Summary

The deficiency involves the facility’s failure to provide basic life support (BLS), including CPR and appropriate choking interventions, to a resident in distress prior to EMS arrival, in accordance with AHA/BCLS guidelines, physician orders, and the resident’s advance directives. The resident was an elderly female with diagnoses including senile degeneration of the brain, CHF, type 2 diabetes, atrial fibrillation, respiratory failure, muscle weakness, and a cardiac pacemaker. Her MDS indicated severe cognitive impairment, need for assistance with eating and mobility, incontinence, and a mechanically altered diet. Her care plan noted a diet other than regular but did not address choking risk.

On the morning of the incident, video footage showed the resident seated in the dining room in a wheelchair, eating breakfast when she began to choke. LVN A responded promptly after the resident gestured to her back, and LVN A began lightly tapping the resident’s back. The resident violently shook her head "no" and later appeared to vomit, then nodded "yes". LVN A continued lightly patting the resident’s back and appeared to yell for help. The resident’s body then became limp and unresponsive while still in the wheelchair. LVN A briefly left toward the edge of the dining room, then returned, and RN B entered the dining room. LVN A resumed lightly patting the resident’s back, then positioned the resident’s limp body forward with her head on the table and began more aggressive back patting. During this period, appropriate back blows and the Heimlich maneuver were not performed for over a minute while the resident was in distress and then unresponsive.

MA C then attempted the Heimlich maneuver while the resident remained limp in the wheelchair, followed by RN B attempting the Heimlich maneuver after the wheelchair was moved away from the table. RN B also attempted to shake the resident’s shoulder while MA C appeared to perform a sternal rub. Staff then pushed the resident in the wheelchair out of the dining room toward a nearby room to initiate CPR. The facility’s own timing and observations indicated that CPR initiation was delayed by approximately two minutes after the resident became unresponsive. The facility’s choking/aspiration policy addressed signs of choking and use of the Heimlich maneuver, including abdominal thrusts if the resident was on their back, but did not address what to do if the resident became unconscious or non-responsive. The facility’s CPR policy required at least one staff member trained in CPR/BCLS at all times and that trained staff maintain current certification.

Record review showed that LVN A’s BCLS certification had expired, RN B’s BCLS certification had expired, and MA C was not currently certified in BCLS. Interviews confirmed that LVN A believed back slapping was the right action when she suspected choking and that she was scared and felt the event "felt like an eternity". RN B reported that when she arrived the resident was already blue and purple and unresponsive, that she checked the code status, called 911, and then attempted the Heimlich maneuver even though the resident was unconscious, acknowledging she panicked and knew CPR should be initiated when a choking victim becomes unresponsive. These actions and inactions—failure to promptly perform appropriate back blows and Heimlich on a conscious choking resident, failure to initiate CPR immediately once the resident became unresponsive, and allowing staff to work with expired or absent BCLS certifications—resulted in the resident not receiving basic life support while choking and constituted the cited deficiency.

Removal Plan

• Conduct an audit of all residents who expired in the facility during the last 30 days to ensure CPR was performed according to AHA/BCLS guidelines, including the Heimlich maneuver.
• Conduct an audit of all charge nurses for current CPR/BCLS certifications.
• Provide CPR/BCLS classes for all charge nurses to ensure current certifications, including return demonstration of skills (including the Heimlich maneuver).
• Provide 1:1 in-service training for the Administrator and ADON (with post-test) on: Abuse and Neglect policy (including failure to perform Heimlich/CPR timely as potential neglect), Cardiopulmonary Resuscitation (initiate CPR immediately when unresponsive with no pulse), and Choking/Heimlich per AHA/BCLS guidelines.
• Provide 1:1 in-service training for LVN A, RN B, and MA C (with post-test) on: Abuse and Neglect policy (including failure to perform Heimlich/CPR timely as potential neglect), Cardiopulmonary Resuscitation (initiate CPR immediately when unresponsive with no pulse), and Choking/Heimlich per AHA/BCLS guidelines.
• Notify the Medical Director of the Immediate Jeopardy citation.
• Hold an ADHOC QAPI meeting to review the Immediate Jeopardy citation(s) and the plan of removal.
• In-service all medication aides and CNAs (with post-test) on: Abuse and Neglect policy (including failure to perform Heimlich/CPR timely as potential neglect) and Notification of change in condition (universal signs of choking and immediate Heimlich per AHA/BCLS; notify nurse; respond immediately); prohibit staff from working their next shift until completed; include new hires during orientation and agency staff prior to shift.
• In-service all charge nurses (with post-test) on: Abuse and Neglect policy (including failure to perform Heimlich/CPR timely as potential neglect), Notification of change in condition (universal signs of choking and immediate Heimlich per AHA/BCLS), Cardiopulmonary Resuscitation (initiate CPR immediately when unresponsive with no pulse), and Choking/Heimlich per AHA/BCLS guidelines; prohibit staff from working their next shift until completed; include new hires during orientation and agency staff prior to shift.