RAPID CITY, SD - An incident involving the death of a resident at Avantara Arrowhead nursing home exposed multiple critical failures in emergency response protocols, resulting in violations related to basic life support requirements during a federal inspection on March 5, 2025.
Emergency Response Breakdown Documented
The inspection revealed significant deficiencies in how nursing staff handled a medical emergency on February 20, 2025, when a resident was found unresponsive in her room. According to the inspection report, multiple staff members failed to follow proper emergency protocols, creating a cascade of errors that compromised patient care standards.
The resident, who had been designated as "full code" meaning she wanted all life-saving measures attempted, was discovered by a certified nursing assistant who immediately called for help. However, the subsequent response by licensed nursing staff failed to meet federal standards for basic life support provision.
Critical Assessment Failures
The most serious violation centered on the registered nurse's failure to properly assess the resident for signs of irreversible death before determining whether CPR was indicated. When the charge nurse responded to the emergency call, he found the resident unresponsive, cold to the touch, and without breathing or pulse. However, he failed to document or communicate crucial clinical findings that would indicate whether resuscitation efforts were medically appropriate.
According to the inspection findings, the licensed practical nurse who assisted observed that the resident's skin was cold, her arm was stiff when manipulated, her chest was not expanding, and she had no heartbeat when checked with a stethoscope. Most significantly, the LPN noted mottled skin on the resident's lower extremities - a clinical sign that typically indicates reduced blood flow and can signal approaching or recent death.
Despite these clinical observations suggesting irreversible death, the nursing staff failed to properly assess and communicate these findings to supervisors. This created confusion about whether CPR should be initiated and led to a significant delay in emergency response.
Communication Breakdown Creates Dangerous Delay
The inspection documented a critical communication failure between the charge nurse and facility administration. When the registered nurse called the administrator to report the situation, he described the resident as "unresponsive and cold to the touch" but failed to mention the clinical signs of irreversible death that staff had observed.
This incomplete communication led the administrator and director of nursing to conclude that CPR should be initiated, as they were not informed of the signs that would indicate resuscitation efforts were not medically appropriate. The decision to attempt CPR was made based on incomplete information about the resident's actual condition.
The communication breakdown extended beyond the initial emergency call. The charge nurse failed to immediately verify the resident's code status, instead walking to the nurses' station when computer access was available on a medication cart directly outside the resident's room. This delay prevented timely decision-making during a critical period.
Emergency Response Protocol Violations
Federal regulations require nursing homes to provide basic life support, including CPR, prior to the arrival of emergency medical personnel, subject to physician orders and advance directives. The inspection found multiple failures in following these requirements during the February incident.
Staff failed to call a "code blue" announcement that would have immediately brought emergency equipment and additional personnel to the scene. The crash cart, which contains essential resuscitation equipment, was not retrieved until later in the emergency response. According to medical protocols, these steps should occur within the first minutes of discovering an unresponsive patient.
The charge nurse also failed to call 911 immediately after determining the resident's full code status. Emergency medical services were not contacted until 9:00 a.m., despite the resident being found around 8:30 a.m. and her code status being confirmed by 8:40 a.m. This 20-minute delay could be critical in emergency situations where immediate professional medical intervention might make a difference.
Medical Standards and Professional Expectations
Emergency response in nursing homes requires rapid assessment and decision-making based on clinical signs and established protocols. When a resident is found unresponsive, nursing staff must quickly evaluate vital signs, check for clinical signs of death, and initiate appropriate interventions based on the resident's advance directives.
The American Heart Association establishes clear guidelines for when CPR is and is not indicated. Signs of irreversible death include rigor mortis (stiffening of limbs), dependent lividity (blood pooling causing discoloration), and other obvious clinical indicators that death has occurred. When these signs are present, CPR is not medically indicated even for full code patients.
Proper documentation of clinical findings is essential for maintaining continuity of care and meeting legal requirements. Licensed nurses are expected to document significant changes in patient status, including emergency situations and any assessments performed. This documentation serves as a critical record for quality assurance, legal protection, and communication among healthcare providers.
The inspection also highlighted the importance of staff training and competency in emergency response. All nursing home staff must be prepared to respond appropriately to medical emergencies, understand code status designations, and follow established protocols without delay.
Impact on Patient Care Quality
These violations represent serious gaps in patient care that could affect multiple residents beyond the individual case documented. Emergency response capabilities are fundamental to nursing home operations, as residents frequently experience sudden changes in medical status that require immediate intervention.
The failure to properly assess clinical signs of death could lead to inappropriate medical interventions that do not serve patients' best interests. Conversely, delays in emergency response for patients who could benefit from resuscitation efforts could result in preventable complications or poor outcomes.
Communication failures between nursing staff and administration can compromise decision-making during critical moments when rapid, coordinated responses are essential. These gaps in communication protocols affect the facility's ability to provide appropriate care during emergencies.
Additional Issues Identified
The inspection revealed supplementary documentation failures that compounded the emergency response violations. The licensed practical nurse who participated in the emergency response failed to document any progress notes regarding the incident in the resident's electronic medical record, despite facility policies requiring such documentation.
The facility's investigation after the incident revealed additional protocol failures, including the charge nurse's failure to direct the emergency response in his role as the shift supervisor. Camera footage review showed the resident had been alert and interactive with staff just hours before being found unresponsive, highlighting the importance of proper emergency response when sudden changes occur.
The inspection found that while the facility had appropriate policies in place, including a "Death Documentation" policy with specific templates for documenting clinical signs of death, staff failed to follow these established procedures during the actual emergency.
Following the incident, the facility implemented comprehensive corrective measures including staff termination, disciplinary actions, facility-wide re-education on CPR and irreversible death policies, verification of all resident code statuses, and initiation of mock code drills to improve emergency preparedness. These changes were confirmed during the inspection as evidence of the facility's commitment to preventing similar violations in the future.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avantara Arrowhead from 2025-03-05 including all violations, facility responses, and corrective action plans.
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