F0678

J

Failure to Provide Timely CPR With Rescue Breaths Due to Ambu Bag Unavailability

Lubbock, Texas Survey Completed on 03-01-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure staff provided basic life support, including CPR with rescue breaths, to a resident who had elected full code status and had corresponding physician orders. The resident was an elderly female with multiple medical diagnoses including a left hip fracture, chronic kidney disease, Type II diabetes, dementia, and anemia, and had a BIMS score indicating severe cognitive impairment. Her comprehensive care plan and physician orders specified Full Code status with interventions including CPR and AED use in the event of cardiac arrest. On the morning of the incident, a staff physical therapist (SP) went to the resident’s room and initially observed the resident breathing but unresponsive, then shortly afterward found her no longer breathing and notified the nurses who were in change-of-shift report.

Two nurses, an RN and an LVN, responded to the room with the crash cart designated for the unit, while another nurse called EMS and CNAs also came to assist. The resident was assessed as having no pulse and no respirations and was moved from the bed to the floor. AED pads were applied and chest compressions were started. Multiple staff interviews consistently indicated that when the nurses requested the Ambu bag for rescue breathing, it could not be readily located on the crash cart. One CNA reported searching the cart, not finding the Ambu bag, and running to the supply room to retrieve one, estimating she was gone about two minutes, while the SP estimated the CNA was gone approximately four to five minutes. Another CNA later reported that during this period she searched the crash cart drawers and found an Ambu bag on the cart after several rounds of compressions had already been performed.

During this time, the nurses and CNAs alternated performing chest compressions, and the resident began to have emesis and greenish-brown secretions from the mouth, requiring suctioning by the RN. Staff reported that mouth-to-mouth breathing was not provided, and that rescue breaths with the Ambu bag were not initiated in a timely manner because the Ambu bag was not immediately available and, once located, could not be effectively used due to the volume of secretions and vomitus. The RN stated that her CPR training included checking responsiveness and pulse, opening the airway, and delivering two rescue breaths with an Ambu bag before starting compressions in a 30:2 ratio, and acknowledged she began compressions without rescue breaths because the Ambu bag was not available. The facility’s written CPR policy specified starting chest compressions, then opening the airway and giving two rescue breaths, and continuing CPR cycles of 30 compressions to 2 breaths. EMS arrived after CPR had been ongoing, took over resuscitative efforts, and the resident was ultimately pronounced deceased at the facility. The administrator and DON later stated their expectation that residents with full code status receive CPR including rescue breaths per policy and protocol, and staff acknowledged that not having essential equipment readily available on the crash cart during an emergency could result in a poor outcome.