Aviata at Tallahassee: CPR Delayed Two Hours - FL
TALLAHASSEE, FL. A registered nurse found Resident #1 with no breathing, no blood pressure, and no pulse at 1:05 PM but called hospice instead of starting CPR.
Nearly two hours passed before anyone began life-saving measures on the full-code resident at Aviata at Tallahassee. By then it was too late.
The August inspection revealed a stunning breakdown in emergency response that violated the resident's explicit wishes for full resuscitation. Multiple staff members knew where to find code status information. Multiple policies required immediate CPR for full-code residents. None of it mattered when the moment arrived.
Staff A, the registered nurse on duty, discovered the unresponsive resident at 1:05 PM. She checked vital signs and found what should have triggered immediate action: respirations 0, blood pressure 0, oxygen saturation 0 percent.
Instead, she reached for her phone.
At 1:09 PM, four minutes after finding a resident in apparent cardiac arrest, Staff A called the hospice nurse to report Resident #1's death. She made no attempt at resuscitation despite clear documentation that the resident wanted every possible life-saving measure.
The resident remained untouched for nearly two more hours.
At 3:00 PM, a different nurse finally noticed something everyone else had missed or ignored: Resident #1 was a full code. Two minutes later, at 3:02 PM, someone finally called 911. Staff began CPR on a resident who had been without vital signs for nearly 120 minutes.
Paramedics arrived at 3:06 PM and continued resuscitation efforts for 19 more minutes. At 3:25 PM, they declared Resident #1 dead.
The resident's medical records contained multiple confirmations of full-code status. An order dated before the incident explicitly stated "FULL CODE," which the facility's own documentation explained "indicates CPR is desired in the event a resident's heart stops beating."
Social services had completed an advance directive discussion confirming the full-code status. Hospice nursing notes from two different dates indicated the same preference. The resident's care plan, revised shortly before death, stated clearly: "Resident has an advanced directive: FULL CODE."
Every staff member interviewed by inspectors knew exactly where to find this information.
Staff B, a licensed practical nurse, told investigators that code status could be found "in the EMR and the advance directives book at the nurses station." Staff E, another LPN, said that for an unresponsive resident, "you would always check for breathing and a pulse and verify the code status of the resident, found in the EMR and the advance directives book at the nurses station."
Staff F explained the process in detail: "A yellow DNR form must be signed and completed in order to not perform CPR. If you have a resident that requires CPR you would document the timeline of events, starting with the condition of resident prior to the code, to the time the residents body is taken out of the facility."
No yellow DNR form existed for Resident #1.
The facility's own policy, titled "Florida Cardiopulmonary Resuscitation (CPR)," could not have been clearer: "Cardiopulmonary resuscitation (CPR) will be provided to all residents who are identified to be in cardiac arrest unless such resident has a fully executed Florida Do Not Resuscitate (DNR) order."
Resident #1 had no DNR order. The policy required immediate CPR.
The Director of Nursing told inspectors that nurses were expected to complete a CPR flowsheet and document a timeline of events whenever CPR was performed. But when investigators reviewed Resident #1's electronic medical record, they found neither document.
No flowsheet existed. No nursing note summarized the event. No timeline explained the two-hour delay between discovering a resident in cardiac arrest and beginning resuscitation efforts.
The absence of documentation meant no one could explain why Staff A concluded the resident was dead without attempting resuscitation. No one could account for why she called hospice instead of 911. No one could justify why nearly two hours passed before anyone checked the resident's code status.
The inspection revealed a cascade of failures that began with the first nurse's decision to pronounce death rather than preserve life. Staff A found a resident who met every clinical indicator for cardiac arrest: no breathing, no blood pressure, no measurable oxygen saturation.
Her training should have triggered immediate CPR. Facility policy demanded it. The resident's documented wishes required it.
Instead, she made a phone call to report a death that hadn't been officially determined.
The registered nurse's actions violated not just facility policy but the fundamental principle of nursing home care: residents who choose full-code status have the right to receive every possible life-saving intervention. When Staff A found Resident #1 unresponsive, she had a legal and ethical obligation to begin resuscitation immediately.
Her failure to act meant that when CPR finally began at 3:02 PM, the resident had been without circulation for nearly two hours. Even the most aggressive resuscitation efforts rarely succeed after such delays.
The four-minute gap between discovering the resident and calling hospice suggests Staff A made an immediate decision that Resident #1 was beyond help. But nurses are not authorized to make that determination for full-code residents. Only physicians or paramedics can declare death after appropriate resuscitation efforts have failed.
The facility's policy acknowledged this responsibility by requiring CPR for all residents "identified to be in cardiac arrest" unless they had executed DNR orders. Staff A identified a resident in apparent cardiac arrest but failed to provide the required intervention.
When the second nurse discovered the full-code status at 3:00 PM, she triggered the response that should have begun nearly two hours earlier. But by then, the window for successful resuscitation had likely closed.
Paramedics worked for 19 minutes to restore circulation and breathing. Their efforts, combined with the facility's delayed CPR, consumed 23 minutes of active resuscitation. Under different circumstances, with immediate intervention, those same efforts might have saved Resident #1's life.
The inspection found that Aviata at Tallahassee had failed its most basic obligation: providing emergency care when residents needed it most. The facility's policies were adequate. Staff training appeared sufficient. Documentation systems existed to track code status.
None of it mattered when Resident #1 collapsed.
The registered nurse who found the resident chose hospice over emergency care, death over life-saving intervention. Her decision meant that a resident who wanted every possible chance at survival received none when it counted most.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aviata At Tallahassee from 2025-08-13 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
AVIATA AT TALLAHASSEE in TALLAHASSEE, FL was cited for violations during a health inspection on August 13, 2025.
A registered nurse found Resident #1 with no breathing, no blood pressure, and no pulse at 1:05 PM but called hospice instead of starting CPR.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.