Safety & Emergency Procedures for CNAs

Falls are the leading cause of injury, hospitalization, and accidental death in long-term care. The Centers for Disease Control estimates that more than half of nursing home residents fall each year, and roughly one in three falls results in injury. For frail elders, even a minor fall can trigger a hip fracture, a head bleed, or a downward spiral of immobility, pneumonia, and decline. CNAs spend more time at the bedside than any other staff member, which means you are the facility's front line for spotting hazards and stopping a fall before it happens.

Risk factors stack on top of each other in older adults. Advanced age weakens bones and balance. Medications such as sedatives, antihypertensives, diuretics, and opioids cause dizziness, drowsiness, and urgency to use the bathroom. Mobility problems from arthritis, stroke, Parkinson's, or recent surgery make transfers unsteady. Confusion from dementia, delirium, or a urinary tract infection causes residents to forget they cannot walk safely. Vision and hearing loss, poor footwear, and environmental clutter add even more risk. Knowing each resident's personal risk profile is the first step in prevention.

Most facility falls are preventable with simple habits. Always keep the call light within the resident's reach before you leave the room, and answer call lights promptly. Lower the bed to its lowest position and lock the wheels on beds, wheelchairs, and Geri-chairs. Make sure the resident wears non-skid footwear or gripper socks, never just hose. Keep pathways clear, turn on adequate lighting at night, and wipe up spills immediately. Offer toileting on a regular schedule, because a full bladder is one of the most common reasons a resident tries to get up alone.

Hourly rounding is the gold standard for fall prevention. Every hour, check the four P's: Pain, Position, Potty, and Possessions. Ask if the resident is comfortable, reposition them if needed, offer the bathroom, and place the phone, water, tissues, and call light within easy reach. If a resident does fall, do not try to lift them off the floor. Stay with them, call for the nurse, and let the nurse assess for injury before any movement. Moving a resident with a fractured hip or spine can cause permanent damage.

Fires in healthcare facilities are rare but catastrophic, because residents cannot evacuate themselves. Every CNA must know the location of the nearest fire alarm pull station, fire extinguisher, smoke door, and exit before an emergency happens. The Joint Commission requires staff to demonstrate fire response procedures, and the NNAAP skills evaluation frequently includes a scenario about responding to a smoke alarm or smelling smoke. The two acronyms you must know cold are RACE for the overall response and PASS for operating a fire extinguisher.

RACE stands for Rescue, Alarm, Confine, and Extinguish or Evacuate. Rescue anyone in immediate danger from the fire first; move residents who are closest to the flames or smoke to a safer area such as behind a smoke door. Alarm comes next: pull the nearest fire alarm and call the facility emergency number to notify the operator and the fire department. Confine the fire by closing all doors and windows in the area to limit oxygen and slow the spread of smoke. Finally, Extinguish the fire if it is small and you have been trained, or Evacuate if the fire is too large.

PASS is the technique for using a portable fire extinguisher and only applies to small, contained fires. Pull the safety pin at the top of the extinguisher. Aim the nozzle at the base of the flames, not at the top, because the base is the fuel source. Squeeze the handle slowly and steadily to release the agent. Sweep the nozzle from side to side across the base of the fire until the flames are out. Always keep an exit at your back, and never fight a fire that is taller than you or growing rapidly.

The fire triangle, sometimes called the fire tetrahedron, explains why fires start and how to stop them. A fire needs three elements: fuel (anything that can burn), heat (a spark or flame), and oxygen. Remove any one and the fire dies. This is why confining a fire by closing doors works so well, and why oxygen-using residents are at extreme risk. Smoking is forbidden anywhere near oxygen, electric razors should replace battery razors with caution, and petroleum-based products such as Vaseline are never used on a resident on oxygen because they can ignite.

Choking is a true emergency because the brain begins to die within four to six minutes without oxygen. Elderly residents are at especially high risk because of weakened swallowing muscles, dentures, dry mouth, dementia, and conditions such as stroke or Parkinson's that impair the swallow reflex. Common causes include eating too quickly, talking while chewing, large pieces of meat or bread, thin liquids in a resident with dysphagia, and pills swallowed dry. Prevention starts with proper positioning during meals: the resident should sit fully upright at ninety degrees and remain upright for at least thirty minutes afterward.

The universal sign of choking is both hands clutched at the throat. The resident may not be able to make any sound at all. First, ask 'Are you choking?' If they can cough forcefully, speak, or breathe, the airway is only partially blocked. Encourage them to keep coughing and stay with them; do not slap their back or perform abdominal thrusts, because that can dislodge the object further down. Call the nurse and continue to observe. A mild obstruction can suddenly become severe at any moment.

If the resident cannot cough, speak, or breathe, the airway is severely blocked and you must act immediately. Call for help, then perform abdominal thrusts, also called the Heimlich maneuver. Stand behind the resident, place one fist with the thumb side against the abdomen just above the navel and well below the breastbone, grasp your fist with the other hand, and deliver quick inward and upward thrusts. Continue thrusts until the object comes out or the resident becomes unresponsive. Each thrust should be a separate, deliberate attempt to expel the object.

Modifications are required for some residents. For a pregnant resident in the later months or a resident who is obese where you cannot reach around the abdomen, use chest thrusts instead. Stand behind them, place your fist on the middle of the breastbone, and deliver inward thrusts. If the choking resident is in a wheelchair, you can perform thrusts from behind the chair. If the resident becomes unresponsive at any point, lower them carefully to the floor, call a code, begin CPR, and look in the mouth for the object before each set of breaths, removing it only if you can see it.

Cardiopulmonary resuscitation is started any time a resident is unresponsive, not breathing or only gasping, and has no pulse, unless they have a valid Do Not Resuscitate (DNR) order on the chart. To recognize cardiac arrest, tap the resident firmly on the shoulder and shout 'Are you okay?' If there is no response, call for help immediately, send someone to bring the AED and crash cart, and check for breathing and a carotid pulse for no more than ten seconds. Agonal gasps are not normal breathing and should be treated as cardiac arrest.

High-quality chest compressions are the single most important part of CPR. Place the heel of one hand on the center of the chest on the lower half of the breastbone, place the other hand on top with fingers interlaced, and lock your elbows straight. Compress at a rate of 100 to 120 compressions per minute and to a depth of at least 2 inches (5 cm) but no more than 2.4 inches (6 cm) for an adult. Allow full chest recoil between compressions and minimize interruptions. The beat of the song 'Stayin' Alive' is the right tempo.

If you are trained in two-rescuer CPR and have a barrier device or bag valve mask, give thirty compressions followed by two breaths, and rotate compressor every two minutes to prevent fatigue. Most long-term care facilities require staff who may perform CPR to hold a current American Heart Association Basic Life Support (BLS) certification or equivalent Red Cross credential, renewed every two years. CNAs are not expected to lead a code, but you are expected to start compressions immediately, call for help, and continue until the nurse, code team, or emergency medical services take over.

Automated external defibrillators (AEDs) save lives by delivering an electric shock that can restart a heart in ventricular fibrillation. Most facilities place AEDs in central, clearly marked locations. As soon as the AED arrives, turn it on, attach the pads to the resident's bare, dry chest as shown on the diagrams, and follow the spoken prompts. The device will analyze the rhythm and tell you whether to shock or to continue CPR. Stand clear during analysis and shock delivery, then resume compressions immediately. Do not use an AED on a wet resident or directly over a pacemaker.

A seizure is a sudden surge of abnormal electrical activity in the brain. In long-term care, seizures occur most often in residents with a history of epilepsy, stroke, brain injury, brain tumor, dementia, low blood sugar, or alcohol withdrawal. A generalized tonic-clonic (grand mal) seizure begins with stiffening of the body (tonic phase) followed by rhythmic jerking of the arms and legs (clonic phase). The resident may cry out, fall, lose bladder or bowel control, bite the tongue, drool, or turn blue around the lips. Most seizures stop on their own within one to three minutes.

Your job during a seizure is to protect the resident from injury, not to stop the seizure. Do NOT restrain the resident or try to hold their limbs still; this can cause fractures or dislocations. Do NOT put anything in their mouth, including your fingers, a spoon, a tongue blade, or medication. The old belief that a person can swallow their tongue during a seizure is a myth, and forcing objects into the mouth breaks teeth, cuts lips, and can choke the resident. Do not give food, drink, or pills until the resident is fully alert.

Do the following: call for the nurse immediately, note the exact time the seizure started, and clear the area of furniture and sharp objects. If the resident is on the floor, place something soft such as a folded blanket or pillow under the head to protect it. Loosen tight clothing around the neck. Do not move the resident unless they are in danger. After the jerking stops, turn the resident on their side (the recovery position) to allow saliva, blood, or vomit to drain out of the mouth and keep the airway clear. Stay with them and provide privacy.

After the seizure ends, the resident enters the postictal phase, which can last minutes to hours. They will likely be confused, drowsy, weak, embarrassed, and may have a headache or muscle soreness. Speak calmly, reorient them gently, and let them rest. Observe and report to the nurse everything you saw: the time the seizure started and stopped, what body parts were involved, the type of movement, any loss of bladder or bowel control, any tongue biting, the color of the skin, and how the resident behaved afterward. Detailed observation drives the medical response.

Accurate reporting is a legal, ethical, and professional duty. Every time a resident falls, is injured, receives the wrong meal, has a medication error, is found in an unsafe situation, or even comes close to being harmed, the event must be documented. Facilities use two main forms: an accident report when actual harm or injury occurred, and an incident report for any unusual event whether or not harm resulted. Many facilities also encourage 'near-miss' reporting for events where harm was narrowly avoided, because near misses reveal system problems before someone gets hurt.

The CNA's role is to report immediately to the nurse and to document objectively. Tell the nurse first, in person or by phone, and then complete the written report before the end of your shift while details are fresh. The report follows the five W's: Who was involved (resident, staff, visitors), What happened in factual detail, Where it happened (room number, location), When it happened (exact time), and Witnesses who were present. Add a sixth question many facilities want answered: What was done immediately afterward, including who was notified.

Documentation must be objective, not subjective. Objective documentation describes only what you saw, heard, smelled, or measured, using direct quotes when possible. 'Resident found sitting on the floor next to bed at 14:20. Stated, I tried to reach the bathroom on my own. Skin intact, no visible bleeding. Vital signs taken, nurse notified at 14:22.' Subjective documentation guesses at cause or assigns blame. 'Resident fell because she is always trying to get up alone' is opinion, not fact, and it can become evidence against you and the facility in a lawsuit. Stick to what you observed.

Incident reports are internal quality-improvement tools, not part of the resident's permanent medical chart. Do not chart in the medical record that an incident report was filed; doing so makes the report discoverable in court. Instead, chart the facts of the event in the resident's nursing notes (what happened, what you observed, vital signs, who was notified), and file the incident report separately according to facility policy. Never alter a report after it is signed, never throw one away, and never ask another staff member to change their version of events.