The incident occurred at Park Avenue Health Center when Resident #1 had requested help getting into a wheelchair earlier that morning. Certified nursing assistant CNA #1 said the resident "appeared to be fine" when she left the room to retrieve supplies from the basement.
When CNA #1 returned to the unit, Nurse #1 told her that Resident #1 "did not appear to be breathing." The two rushed to the room together.
Nurse #1 left to get the code cart and automated external defibrillator while CNA #1 stayed with the resident. When the nurse returned, they transferred the resident from the wheelchair to the floor, applied AED pads, called 911, and Nurse #1 began chest compressions.
CNA #2, working on the same floor, heard Nurse #1 yell her name for help. She assisted in lowering the resident to the floor but was never asked to call a Code Blue. "She was not asked to call a Code Blue and does not remember hearing a Code Blue being paged overhead," the inspection report states.
Multiple staff members confirmed no Code Blue was announced. CNA #4, working on the third floor, said he would have responded immediately if he had heard the emergency call. "If he had, he would respond to help and do what was asked of him."
Nurse #2, also on the third floor during the overnight shift, said she never heard a Code Blue paged. "If she had heard a Code Blue being paged, she would have responded immediately to help."
Nurse #4 arrived for work around 6:15 a.m. that morning but never heard any emergency announcement. She told inspectors that "if she had heard a Code Blue, she would have stopped what she was doing and go to the location announced to help with whatever was needed."
The Assistant Director of Nurses was unaware that Nurse #1 had failed to call a Code Blue. "If he had, licensed staff would have responded to assist," she told inspectors.
The facility's Interim Director of Nurses, who also serves as Regional Clinical Operations director, assumed a Code Blue had been paged. She had not realized that only three staff members handled the emergency.
"If Nurse #1 had called a Code Blue other licensed staff would have been available to help," the interim director told inspectors.
The facility's own policy requires a different response. According to the interim director, when a resident is found unresponsive, "the responding Nurse is to assess the resident, call out for help, and instruct the first staff member to arrive to page a Code Blue."
The protocol calls for the nurse to direct arriving staff members, coordinate retrieval of the code cart and AED, ensure someone calls 911, and manage the emergency until paramedics arrive and take over.
CNA #2 understood the importance of the missing announcement. "When a Code Blue is called other staff come and help," she told inspectors.
The facility had not conducted regular mock Code Blue drills. The Assistant Director of Nurses acknowledged that "the Facility has not had a Staff Development Coordinator for some time and Mock Code Blue's were not being done on a regular basis."
Nurse #4 emphasized the critical nature of the oversight: "The nurse needs to call a Code Blue so that other staff can assist with the emergency."
The inspection found that Nurse #1 should have instructed someone to page the Code Blue "so other nursing staff could have responded in the emergent situation."
Instead, the emergency response relied entirely on one nurse and two nursing assistants, while licensed nurses on other floors remained unaware that a resident was fighting for life just floors away.
The interim director's assumption that proper protocol had been followed highlights a gap between policy and practice. Multiple qualified staff members were available and willing to help, but never knew their assistance was desperately needed during those critical morning minutes when every second counted.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Park Avenue Health Center from 2025-08-28 including all violations, facility responses, and corrective action plans.