F0678

D

Failure to Use Available AED During CPR and Lack of Documented CPR Certification

Raleigh, North Carolina Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to utilize an available Automatic External Defibrillator (AED) during CPR for a resident who was a full code, and the lack of documentation of current CPR certification for the nurse leading the response. Facility policy stated that the HeartSaver level of CPR, as defined by the American Heart Association (AHA), would be provided and that CPR would be initiated immediately for residents following cardiopulmonary arrest unless a DNR order or obvious signs of clinical death were present. The AED policy authorized any licensed nurse trained in AED use to deploy the device in emergencies, specified that staff would maintain CPR certification, and directed that the AED be used in tandem with CPR during a Code Blue, with the crash cart and AED to be immediately deployed to the location of the unresponsive individual.

The resident involved had chronic atrial fibrillation and was admitted with a physician’s order and care plan indicating full code status. She was cognitively intact on admission and was not receiving anticoagulant medication. On the night of the event, Nurse #1 reported that the resident had been her usual self and had spoken to her around 2:30 AM. Sometime after 5:00 AM, Nurse #1 found the resident unresponsive, not breathing, and without a pulse, though still warm. Nurse #1 called a Code Blue, 911 was called, and the crash cart was brought to the room. Nurse #1 and Nurse #2 moved the resident to the floor; Nurse #2 performed chest compressions while Nurse #1 provided ventilations with an Ambu bag connected to 15 liters of oxygen. EMS records confirmed that upon their arrival, CPR was already in progress and that EMS personnel placed the monitor in AED mode, with no shock advised, and the resident remained in asystole despite advanced life support.

Despite facility policy and the presence of an AED mounted on the wall above the crash cart on the 100 Hall, Nurse #1 did not bring or apply the AED during the Code Blue. She stated that everything happened quickly and she did not think to bring the AED, and that although she recalled AED instruction during CPR training, she was not aware it was something she had to use, so she and Nurse #2 focused solely on CPR until EMS arrived. Nurse #2 similarly reported that he did not recall an AED being present and that in prior Code Blues he had not used an AED, concentrating instead on CPR. Another nurse (Nurse #3), who arrived after CPR had begun, described the facility’s expected procedure as including bringing and applying the AED and following its prompts, indicating that staff understanding of AED use was inconsistent. The Central Supply Clerk confirmed that the AED on the 100 Hall was functional and checked monthly. Additionally, the Administrator acknowledged that the facility did not have a copy of Nurse #1’s current CPR certification on file at the time, even though facility policy required staff to maintain CPR certification, resulting in a failure to maintain documentation of current, valid CPR certification for Nurse #1.