Charleston Rehab: AED Failure During Cardiac Emergency - IL
The resident had returned from the hospital with acute respiratory failure just days before the September cardiac emergency at Charleston Rehab and Nursing. Staff found him unresponsive and not breathing, then rushed to get the facility's crash cart and defibrillator.
Registered nurse V25 hooked the AED to the resident's chest while certified nursing assistants performed chest compressions. The device wouldn't work.
"The AED would not work I don't know if the battery was dead or what the problem was," V25 told investigators. Staff continued CPR with manual chest compressions and an Ambu bag until paramedics arrived. The resident was pronounced dead after 20 minutes of resuscitation efforts.
The facility's Director of Nursing later admitted the AED hadn't been checked since "last of June" — months before the emergency. Federal regulations require daily equipment checks to ensure medical devices function properly during emergencies.
"The AED should be checked daily. We have a form we use to check off the equipment was checked," the nursing director told inspectors. But the form wasn't completed between late June and the September emergency.
The resident had been in declining health since his hospital return. Progress notes from his admission showed he'd been diagnosed with acute respiratory failure with hypoxia. On the morning of the cardiac emergency, staff noticed his head was bent over, his pulse was weak, and his breathing had slowed dramatically.
V25 immediately called emergency medical services while nursing assistants V26 and V27 moved the resident to his bed with a cardiac board positioned behind his back. The registered nurse then requested the crash cart as the resident's condition deteriorated.
When V26 returned with the emergency equipment, V27 was already performing chest compressions. That's when V25 discovered the AED malfunction that would define the emergency response.
The facility no longer has an AED on site, according to the nursing director's statement to investigators. She maintained that the device failure didn't change the resident's outcome, noting that staff "started doing the CPR procedure immediately."
But federal inspectors found the equipment failure violated requirements for maintaining essential medical devices in working condition. The facility's own undated policy on automated external defibrillators specifically requires staff to "check the device and perform maintenance tasks, as directed in the AED Manual."
The resident's body was transported to the local hospital morgue after paramedics completed their resuscitation attempts. He hadn't listed a funeral home preference on his admission paperwork.
Federal investigators discovered the equipment failure during a complaint investigation at the facility. The violation was classified as causing "minimal harm or potential for actual harm," but highlighted a critical gap in emergency preparedness.
Automated external defibrillators are designed to analyze heart rhythms and deliver electric shocks to restore normal cardiac function during sudden cardiac arrest. The devices include voice prompts to guide users through emergency procedures, but only function when properly maintained and charged.
The nursing director's acknowledgment that daily checks weren't performed contradicted the facility's written maintenance policy. The gap between the last equipment check in June and the September emergency represented a period of unknown device functionality.
Emergency medical services personnel took control of the resuscitation effort upon arrival, but the resident couldn't be revived despite extended CPR attempts. The coroner was contacted as required for the facility death.
The incident exposed broader questions about emergency preparedness at Charleston Rehab and Nursing. While the facility maintained policies requiring daily equipment checks, actual practice fell short of written procedures.
Staff members involved in the emergency response demonstrated knowledge of proper CPR techniques and emergency protocols. V25 immediately recognized the cardiac emergency and coordinated the response, while nursing assistants quickly moved the resident and retrieved emergency equipment.
But the AED failure highlighted the critical importance of routine equipment maintenance in healthcare settings. The device's malfunction during a life-threatening emergency underscored how equipment neglect can compromise patient care during critical moments.
The facility's decision to remove the AED entirely following the incident suggests ongoing challenges with maintaining emergency medical equipment. Federal inspectors noted the violation affected "few residents" but represented a systemic failure in equipment management protocols.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Charleston Rehab and Nursing from 2025-09-02 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 19, 2026 · Our methodology
Charleston Rehab and Nursing in CHARLESTON, IL was cited for violations during a health inspection on September 2, 2025.
The resident had returned from the hospital with acute respiratory failure just days before the September cardiac emergency at Charleston Rehab and Nursing.
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.