June brought another tragic reminder of why emergency code preparedness must remain a priority in every senior living community. The headline, “State: Woman died after nursing home failed to perform CPR”, is heartbreaking, but unfortunately, it is not the first time a situation like this has occurred. As I read the article, I immediately noticed several red flags. Each one serves as a reminder that emergency response depends on preparation long before an emergency ever happens.
First, the community maintained a binder containing each resident’s code status. Why? With today’s electronic medical records, code status should be available within seconds. Maintaining duplicate documentation, especially for something as critical as code status, increases the risk of conflicting information. Eliminate duplicate records whenever possible.
Second, staff could not administer oxygen immediately because the necessary attachments and cannulas were missing. That delay could have serious consequences during an emergency. Assign one person to routinely inspect emergency equipment. Staff sometimes borrow supplies during resident care and accidentally fail to replace them. A simple checklist attached to the emergency cart can help confirm that all equipment is present, functioning properly, and ready when needed.
Third, when first responders arrived, no one was performing CPR, even though the nurse had confirmed in the medical record that the resident was a full code. Have your caregivers been trained on the fundamentals of CPR? While some states allow registered nurses to pronounce death under certain circumstances, once staff initiate CPR and call 911, they should continue CPR until first responders take over.
Finally, the emergency cart never made it into the resident’s room during the incident. Nursing education teaches caregivers to bring the emergency cart to every code. In this case, staff had fully stocked the cart and left it at the nurses’ station, but no one brought it to the bedside.
These lessons reinforce why emergency code preparedness requires more than written policies. Before you leave today, take a few minutes to inspect your emergency carts. Verify that the locks are intact and all equipment is available. Tomorrow, consider holding an unannounced code drill. Evaluate how your staff respond. Who retrieves the emergency cart? Who calls 911? Who begins CPR? The answers may surprise you.
It is also worth partnering with your local fire department or Red Cross chapter to refresh CPR skills on a regular basis. Ongoing education can make a tremendous difference when seconds count.
For additional guidance, HealthCap members can review the following resources:
- Cardiopulmonary Resuscitation (CPR) Policy & Procedure
- Heimlich Maneuver
- Full Code Documentation Policy & Procedure
- CPR Full Code Documentation
- Automatic Electric Defibrillators Policy & Procedure
Stay well and stay informed!
