Holton v. Artesian Waters, LLC

ARTESIAN SPRINGS RESORT

Artesian Springs Resort, located in Newton, Texas, is a 100+ acre camping and recreation facility in the Piney Woods of Eastern Texas. According to their website, the resort offers “premium campsites” for RV and tent camping, as well as rustic cabins. Other amenities include an approximately 2 acre natural swimming hole and beach, picnic tables and grills, party pavilions, fishing, hiking, paintball, a playground, and games, including horsehoes, water volleyball, 1/2 basketball court, and a mini putt course. The resort also includes indoor showers, laundry facilities, a General Store and Office, and several fishing lakes.

The depth of the lake goes from 0′ to a maximum depth of 40′. There is a large slide to the left of the blue dock. The landing area for the slide is approximately 12′ – 15′ deep. There is usually an attendant assigned to the slide to control the dispatch of sliders.

The park and swimming area is open from 9:30 AM to 7:00 PM. During the 2008 season, the park experienced between 20,000 and 30,000 visitors. On a busy weekend, there could be as many as a thousand people in the park at any time. Memorial Day Weekend, July 4th, and Labor Day Weekend are the busiest weekends at the resort. There is no established maximum capacity for the swimming area.

There is a lifeguard station on the blue dock adjacent to the slide. Although there are two lifeguard stands on the dock, there is typically just one lifeguard assigned to that station. And, the lifeguards typically work a 5-hour shift.

The resort is owned and operated by Elisa Leung and her husband, and was purchased by them in March 2008 from Lawrence and Francine Gordon. The Leungs had no previous experience running a facility like this, nor have they participated in any type of management, lodging, or aquatics facility operations and/or management training.

Elisa Leung was responsible for hiring and firing the lifeguards during the summer 2008 season. She basically hired the lifeguards from the previous year/owners. According to Ms. Leung, she has never consulted with anyone regarding lifeguard operations at the park and had never had an audit of the lifeguard operations performed. There is no Standard Operating Procedures (SOP) Manual, but according to Ms. Leung, there is a Lifeguard Manual that is kept in the office, and the park subscribes to Aquatics International Magazine. When Ms. Leung was asked about any written policies or standards that are followed with regard to the lifeguarding program at the resort, she replied, “Yes, the Red Cross”. There is a “Lifeguard Book” in the office that contains schedules for the lifeguards, Lifeguard Rules, Slide Rules, Incident Reports, etc. It also contains an Emergency Action Plan copied directly from the American Red Cross Lifeguard Manual. According to Ms. Leung, this book was inherited from the previous owners.

There had been a previous drowning incident of a young child while the resort was owned by the previous owners. Since the Leungs purchased the resort, there had been no previous significant incidents.

Artesian Springs Resort is open year-round, but the season is considered between May 1 and Labor Day. During the “off season” Herbert (Sonny) Martin and his wife, Peggy, are the caretakers. On the day of the incident, Sonny had been present at the time. He lived on the property, but was not an employee at that time. During the 2009 season, Sonny Martin served as the Beach/Lifeguard Manager after recently completing a lifeguard training course conducted at the park just prior to the beginning of the season.

Kim Poplin served as the Lifeguard Manager during 2008. Her responsibilities included helping with the schedule of the lifeguards and she “walked the beach”. She also relieved the lifeguards when they needed a break. Kim had an “open water lifeguarding” certification, but she was the only lifeguard at the resort with this level of certification. In addition to serving as the Head Lifeguard, she also worked as the Office Manager and Reservationist. “I did pretty much everything. If it needed to be done, I done it.”

According to Ms. Poplin, as the Head Lifeguard, “I had to make sure that the beach was covered if the lifeguards needed to be there. I made sure that they were doing the job that they were supposed to be doing. I have a lot of teenagers that might like being in there and just playing around, and I don’t deal with that.” She was also responsible for setting the lifeguard schedules, and had supervisory responsible over the lifeguards.

Ms. Poplin admitted that the lifeguards were not evaluated at the beginning of the 2008 season, “because I honestly didn’t start right when the rest of the lifeguards did. I came in right after they did, and they were already doing their own thing. They had another Head Lifeguard over them…Helen…was the Head Lifeguard over them, because she was the year prior at the end because I wasn’t lifeguarding them.” Ms. Poplin doesn’t know whether or not Helen had been Waterfront certified or not. Ms. Poplin took over the job as Head Lifeguard in middle to late June of 2008.

Ms. Poplin had started working there in 2003 and in 2006 she started lifeguarding because, according to her, “they needed more responsible people to be able to do lifeguarding, so I started lifeguarding out there in ’06.” She got certified as a Waterfront Lifeguard at that time. “I got a certification card on open water lifeguarding. I got a certification card on first aid, CPR, and being able to use that AED, the defibrillator.” She has not had any other lifeguard, Lifeguard Management, rescue or EMS training since that time.

Robert Windham completed his Lifeguard Training and CPR on April 30, 2007. His lifeguard training was conducted entirely in a swimming pool setting. He had no open water training whatsoever. Although his Lifeguard Training certification was valid through April 30, 2010, his CPR certification expired on April 30, 2008.

Prior to his starting work as a lifeguard at Artesian Springs in 2007, Mr. Windham filled out an application, showed his certificate, and was hired on-the-spot as a lifeguard. At age 15, this was his first and only job as a lifeguard. There was no vision assessment, nor was there any type of evaluation of his knowledge or skills. According to Lifeguard Windham, “they didn’t give me a test or anything.” The Head Lifeguard at the time was Ashley Hatton and she was in charge of the lifeguards.

Robert Windham was re-hired as a Lifeguard for the 2008 season. According to Elisa Leung, who hired the 2008 lifeguards, “everyone showed me their lifeguard cards, and I saw them.” No assessments or evaluations were conducted of the lifeguard candidates’ skills or knowledge, no site-specific training was conducted, no in-service training was conducted, no Emergency Action Plans (EAPs) and/or Emergency Response Plans (ERPs) were developed or practiced, and no Standard Operating Procedures (SOP) Manual was developed or provided. According to Ms. Leung, there was no pre-service or in-service training, and no emergency drills or audits were conducted. But, she did state, “we had a meeting in which we discussed the rules.” And, that “additional training is not provided because they were fully certified at that point.” According to Ms. Poplin, she didn’t conduct any pre-season training, “because I wasn’t there whenever they were….” And, “once I started in there, it was so busy it’s hard to get anybody unless you get into that water to get them to do anything like that.” She also didn’t conduct any Search and Rescue training, and doesn’t know whether or not that was done the previous year under Helen. When Ms. Poplin was asked whether there was a search and rescue plan in place, she stated, “in the training they teach you how you are supposed to search out for a rescue in the case of a drowning.”

According to Lifeguard Windham, the lifeguards were not provided any kind of lifeguard rules or operating procedures; “they just gave us like what were already on the signs that were put up out there.” According to Lifeguard Windham, “they never taught us anything.”

As part of his lifeguard uniform, Lifeguard Windham was not provided any type of hat or visor, nor was he provided or required to wear sunglasses while on duty. According to Ms. Leung, “they can wear hats if they’d like, because it’s very hot obviously out there, and most of them do.” According to Lifeguard Windham, if you wanted to wear sunglasses, you had to bring your own and that they were not required. When asked whether or not he wore sunglasses while lifeguarding, he stated he didn’t wear sunglasses. According to Ms. Leung, sunglasses are not provided, but the lifeguards are supposed to wear sunglasses. She stated, “I think it is a written policy.” According to Ms. Poplin, “he should have been (wearing sunglasses). If he doesn’t he gets a bad headache…. They are supposed to wear glasses.”

During the 2008 season, it was not uncommon to have only one (1) lifeguard on duty to cover the entire swim area. According to Lifeguard Windham, “in 2007, we had a lot more lifeguards than we did last year (2008), so we normally had two or three lifeguards a day, everyday, and shift working.” And, “one of the lifeguards would be patrolling the beach…and then one of us would be sitting there for an hour, and then we would switch places by the hour, and the other one would patrol the beach and the other one would sit in the chair.”

The water depths of the park range from 0′ to 40′ in depth, with the depths under the slide at 12′ to 15′. The lifeguards were not trained in waterfront lifeguarding and had no site-specific open water training. Masks, fins, and snorkels were not provided, and lifeguards were not trained in the use of this equipment or in Search and Rescue procedures for submerged victims. There may have been goggles that were available, but Lifeguard Windham received no training in the use of this equipment. When asked about the location of the goggles, he replied that they were kept “either up there on the chair by the lifeguard stand or in the closet by the lifeguard stand.” However, according to Ms. Leung, she stated there were masks and snorkels available for the lifeguards and that they were available during the 2008 season, because they were required by the Red Cross for use in the Waterfront Lifeguarding course.

Mr. Leung stated that the lifeguards are rotated after approximately 1 – 1.5 hours. “They might be on for an hour or an hour and a half, and then they send the next person.” According to Ms. Poplin, a normal shift was five or six hours, and “I would not allow somebody to work over ten hours.” The entire swim area was only protected by one lifeguard and that, according to Ms. Poplin, “if they work five hours, they are up there for like two and a half, they get thirty minutes off, and then they work another two and a quarter or two and a half…. On that Sunday, he (Lifeguard Windham) was actually working the full day shift…. So we told him he could go ahead and work the full day shift if he thought he could handle it, and if he needed help for him to call me out there.”

Lifeguard Windham stated that, “in 2007 we had a lot more lifeguards than we did (during 2008), so we normally had two or three lifeguards a day, everyday, and shift working.” During 2008, that changed because there were fewer lifeguards on staff. During the 2008 season, although there were two lifeguard stands, there was just one designated lifeguard station located on the blue dock, and there was typically just one lifeguard on duty at a time. The typical lifeguard shift was for five (5) hours. And, according to Lifeguard Windham, the lifeguard sits there “most of the time unless you have to go to the bathroom.” According to Lifeguard Windham, he had discussed the lack of lifeguards with Kim Poplin and that “we always had discussions about needing more lifeguards.”

On the day of the incident, Lifeguard Windham was the only lifeguard on duty. His Zone of Responsibility was the entire swimming area. Prior to the incident, he had had a bathroom break during which time Sonny had relieved him. According to Lifeguard Windham, when he was alerted to the incident, there were more than 50 people in the water. Yet, according to Ms. Leung, she thinks the Red Cross suggests 1 lifeguard for 15 – 20 patrons. She also stated that the most patrons she’s seen in the facility at any one time was approximately 75 patrons.

Artesian Springs Resort, according to Ms. Poplin has numerous hazards. “You walk, and then all of a sudden there’s a sand bar, and then there’s a drop off. You go down. It’s not a gradual going down. You go out to about four or five feet deep, and then it just starts dropping off.” Yet, only one lifeguard is stationed at a time, and no surveillance protocols were established. When Ms. Poplin was asked about the 5-minute scanning strategy, she replied, “every five minutes you should be looking at every part of that beach.”

According to Ms. Poplin, the Resort has approximately 6 lifeguards on staff, but stated, “we don’t have a certified lifeguard on the slide at all times because it’s somebody that has to sit there just to make them sit and do it correctly instead of them hurting themself by trying to flip onto the slide.” On the day of the incident, her daughter, Lisa, was the slide attendant, Lifeguard Windham was the sole lifeguard, and according to Poplin, “but there wasn’t that many people out there.”

DESCRIPTION OF THE INCIDENT

On July 6th, 2008, Conitria Smith and her family drove to Artesian Springs Resort to celebrate her daughter’s birthday. There were 14 – 16 individuals in the party, consisting of 5 adults and the rest children, including 10-year-old Justice D. Smith. They had reserved a cabin (#15) for the day and had planned to let the children play at the resort and have a Bar-B-Q to celebrate Brittany’s birthday.

The family drove to the Artesian Springs Resort in four vehicles and the first group arrived between 2:30 PM and 3:00 PM. Upon their arrival, they paid their fees, received parking passes, and were provided wrist bands for identification purposes. They then proceeded to unload the vehicles and set up the bar-b-q in front of Cabin #15.

Conitria Smith, Justice’s aunt, had arm floaties for most of the children and rented several innertubes from Artesian Springs Resort for the other children. The majority of the children with her party were non-swimmers. She was aware that Justice could dog-paddle and could keep his head above the water. Conitria was not aware there were life vests available for use provided by the resort or that they were available to the resort guests free-of-charge.

While Conitria was supervising the children in the water, her mother arrived at the park office. Conitria then left the swimming area to go register her mother and the rest of the family. Her father, Charlie Smith, kept an eye on the children while he was cooking at the Bar-B-Q grill. According to Mr. Smith, “we (he and Conitria) both was keeping an eye on them, because I was back and forth from the sand to the fence.”

According to Conitria Smith, Justice had been playing with Conitria’s daughter, Alexia. “That was the last time that I saw him. He was over there talking and playing with Alexia…. They was at the edge of the water … the shallow bed part of the water…. They was just sitting down and playing and talking.”

When Conitria returned to the lake from the office, the adults called all the children out of the water to go up to the cabin to eat. According to Conitria, “I went to look for him (Justice). I didn’t see him. We came back and we called the kids in to eat, and I didn’t see him… My little brother, Chardric, went to the restroom to see was Jay there.”

Lifeguard Whitman had been sitting in the lifeguard chair on the blue dock when, according to Whitman, he “noticed a man standing behind me, looking around. After about 5 minutes, I asked him if he was looking for something. He said, yeah, I lost my little boy…. So, I told him ‘okay’ I will call the office.” Lifeguard Whitman then radioed the office and told Ms. Poplin about the missing child. There were no standard procedures at Artesian Resort, either in writing or practiced for this type of situation, other than the Red Cross Emergency Action Plan (EAP). According to Lifeguard Whitman, “At the time, he did not say the kid was in the water, he just said he had lost him.” Lifeguard Whitman then told Kim to perform a land search. Then, “after about 7 minutes, I asked him where was the last place he was seen. And he said he was playing in the shallow water with the other kids.”

According to Kim Poplin, “at approximately 3:30 PM the lifeguard on duty, Bobby Windham, called me on the radio stating that a boy was missing…. I was in the office and Bobby radioed to me. He said that he thought that there was a problem, that there was a gentleman walking around behind the deck looking like he had lost something. He said he was fixing to get down off of the dock, and normally if he has to leave off of the deck and I’m in the office, I’ll run out of the office to the front gate and go and see if I can watch what’s going on from there, because if nothing else I could scream.”

At the time Lifeguard Windham radioed the office to inform them of the missing boy, he did not state it was a missing bather, “because’, according to Lifeguard Windham, ‘he didn’t tell me at that time that he had left him in the water.” So, Lifeguard Windham called the office and told them to look around the campus. When Lifeguard Windham radioed, Kim took the radio and then left to go search the park. Brittany had gone to the office and, according to Ms. Leung, she “told the staff that she needed help as a boy was missing and they couldn’t find him. One of the staff members, Ms. Poplin, took the girl to look for the boy in the campground golf cart. They were unable to locate him and returned to the office” approximately 20 minutes later. Ms. Leung then took the girl back out to continue looking for the boy.”

According to Lifeguard Windham, “they called back in like ten minutes and said that he wasn’t nowhere on the campus to be found.”

Lifeguard Windham then asked the man where he left the child and the man said he had left him right here, and “that’s when I realized we had a problem.” According to Lifeguard Windham, that was approximately 15 minutes after he had initially talked with the grandfather and realized the child was missing. Lifeguard Windham then got Sonny and another person to start walking around in the water to perform a search in shallow water. He stated that prior to the search he cleared the lake, but that is disputed by Ms. Leung.

Ms. Leung then asked the cousin whether or not Justice could swim. When the child said “No”, she then drove directly to the beach. Upon arrival at the beach, she was met by Sonny who stated the boy was last seen standing at the bank where they were standing. Sonny also stated that he and Lifeguard Windham had been searching the water for the child. Ms. Leung observed there were 10 – 20 swimmers still in the water.

After driving through the park to look for Justice, Ms. Leung then took Brittany to the swimming area where she learned that the boy had last been seen near the lake. When Ms. Leung drove to the lake with Brittany, she ran to the lifeguard stand where Sonny Martin was standing. According to Ms. Leung, “he told me that the boy was last seen standing at the bank where we were standing and that he (Sonny) and the lifeguard had been searching the water.” She then observed Lisa Schweifler, the slide attendant, in the water with two other girls, who had also been looking for Justice.

When Justice was reported missing, a search was initiated in the shallow end of the lake by Lifeguard Whitman and several guests. According to witness Rochelle Muff, “we all immediately began searching all around the water.” Lifeguard Whitman, along with a friend (Josh) then “started scanning the shallow water up and down from where the Grandfather said he was last seen.”

During the search, Ms. Poplin never went to the water area to assist or supervise because, “Miss Lisa was down there at the water when all this stuff was going on.” Although she did state that, “you need to start a water search no matter what, if you know if they are in there or not.”

Elena Trotta, Elisa Leung’s mother, had been in the office when they were notified of the missing child. She went to the lake and on arrival there observed the lifeguard, “at the top of the platform.”

After the shallow water search, Lifeguard Windham decided to check under the low dive, because according to him, “we’ve looked everywhere else and I didn’t think that anybody had looked under there until Lisa told me she did.” According to Whitman, “I went under the water near the low dive straight out about 2 – 3 feet and found him. I came back up and went down again to get him.” Justice was found, according to Sonny Martin, five to seven feet near the steps of the lower diving deck. The total time he was missing was approximately 20 – 30 minutes.

Ms. Leung then yelled to “clear the water”, at which time someone ran up to her and stated he was a medic who then helped pull Justice from the water. According to Ms. Leung, “the medic, with two other women who were nurses, proceed to do CPR.”

Once the child was recovered by Lifeguard Whitman, Rochelle Muff’s daughter, Rayma, along with several others at the park initiated CPR on Justice. According to Ms. Muff, “No one gave up despite the fact the face mask in the first aid kit was too big, despite the fact as trained nurses we needed suction, endotracheal equipment, and an ambu bag. But, as first aiders, these things were not in the kit.” The patrons continued to provide basic life support CPR to Justice until the ambulance arrived, approximately 30 – 45 minutes later.

Although the Resort had one adult and one pediatric Bag-Valve-Mask (BVM) Resuscitator, there was no manual Suction equipment, oxygen administration equipment, or an automated external defibrillator (AED). Ms. Poplin stated, “we weren’t allowed to keep rescue stuff in it, ambu bags, stuff like that, because we were not certified to be able to carry them…. And, we can’t use any oxygen or anything like that out there. I asked them if we could, and they said no.”

Lifeguard Windham thought there was an AED in the office, but it was not requested during the resuscitation efforts on Justice. Yet, Lifeguard Windham did not know what a BVM was; he didn’t know they were kept in the office, and no one called for its use during the resuscitation efforts on Justice. According to Ms. Leung, there was not an AED, “because they are like $2,000 to buy one.”

The nearest ambulance from Bon Wier is approximately 15 – 30 minutes away. The hospital is approximately 45 minutes away. At approximately 5:00 PM on this date, Deputy Jay Matthews of the Newton County Sheriff’s Office was dispatched for a possible drowning at Artesian Springs. He arrived on the scene, simultaneously with a first responder, at 5:06 PM, and observed Justice Smith out of the water and receiving CPR.

Priority One ambulance received the call and was dispatched to the scene at 4:58 PM. They arrived on the scene at 5:15 PM and took over resuscitation efforts. On arrival, Justice was unresponsive and presented in full respiratory and cardiac arrest, with no neurological activity. Capilary refill was absent, lung sounds were absent, and pupils were fixed. He showed a low SPO2 as well. EMS personnel administered positive pressure ventilation, using a Bag-Valve-Mask Resuscitator with the administration of supplemental oxygen ad 15 LPM. His airway was suctioned, CPR was maintained, and the patient was intubated. ACLS drugs were administered prior to and during transport to the hospital.

Justice was then transported to Jasper Memorial Hospital at 5:21 PM with CPR in progress and arrived at the hospital at 5:48 PM. Resuscitation efforts were continued at the hospital until death was pronounced shortly thereafter.

BREACHES IN THE STANDARD OF CARE

10-year-old Justice D. Smith experienced an unrecognized submersion incident on July 06, 2008 and died as a result of this incident. The actions or inactions of the owners, managers, and lifeguard personnel either caused or contributed to his death. Based on my review of the materials previously identified, it is my opinion that there were numerous breaches in the standard of care. As a result, they failed to prevent this incident. They failed to recognize the incident, as well as its potential. And, they failed to effectively manage the incident, as well as its potential.

The owners, managers, and lifeguard personnel at the Artesian Springs Resort:

1. Failed to assess the number of patrons using the facility and failed to strategically position lifeguard personnel to safeguard the public engaged in aquatic recreation activities within the non-swimmer and swimmer areas of the park.

2. Failed to recognize that weak or non-swimmers are at heightened risk of they are allowed to progress beyond the non-swimmer area of the park.

3. Failed to recognize that a lapse in supervision is to be expected by parents who are supervising more than one child at a time and they failed to implement appropriate and additional layers of protection to safeguard young children engaged in aquatic recreation activities within the non-swimmer and swimmer areas of the park.

4. Failed to recognize that young children are attracted to water and have little concept of the dangers associated with water, and that the actions of young children around the water is unpredictable.

5. Failed to realize that drowning is a silent death and that drowning victims do not call out and wave for help and that lifeguard personnel need to be strategically positioned and vigilant in their duties.

6. Failed to recognize Justice progressing into deeper water that was beyond his capabilities, and failed to recognize signs of distress as displayed by Justice prior to and during the drowning process.

7. Failed to intervene and provide rescue before the onset of respiratory and cardiac arrest.

8. Failed to assess the public safety needs required by the physical nature of this facility and failed to establish appropriate lifeguard stations needed to provide effective patron surveillance and rescue.

9. Failed to identify physical hazards that existed at this facility, and they failed to remove, correct, or warn patrons of these hazards.

10. Failed to identify those activities that place patrons at heightened risk and failed to either safeguard or prohibit those activities.

11. Failed to provide vigilant and effective patron surveillance and supervision by competent and qualified lifeguard personnel.

12. Failed to provide state-of-the-art safety and rescue equipment to include:
a. Personal Resuscitation Masks
b. Bag-Valve-Mask Resuscitators
c. Elevated Lifeguard Stands
d. Manual Hand-Held Suction Devices
e. Automated External Defibrillators
f. Oxygen Administration Equipment
g. Masks, fins and snorkel for search and rescue

13. Failed to appropriately train lifeguard personnel to recognize hazards and risks to prevent submersion incidents of young children.

14. Failed to educate the public about the hazards and risks, and they failed to establish rules and regulations and facility-use-guidelines for parents to safely and effectively supervise young children engaged in aquatic recreation activities in the non-swimmer and swimmer sections of the facility.

15. Failed to implement appropriate Layers of Protection to safeguard young children engaged in aquatic recreation activities in the non-swimmer and swimmer sections of the facility.

16. Failed to prohibit weak and/or non-swimmers from progressing out to and beyond the lifeline separating the non-swimmer from the swimmer sections of the facility.

17. Failed to establish appropriate and effective surveillance protocols to be used by lifeguard personnel to safeguard patrons engaged in aquatic recreation activities in the non-swimmer and swimmer sections of the facility.

18. Failed to train lifeguards in appropriate and effective surveillance protocols to be used to safeguard patrons engaged in aquatic recreation activities in the non-swimmer and swimmer sections of the facility.

19. Failed to assess the lifeguards’ ability to appropriately and effectively safeguard patrons engaged in aquatic recreation activities in the non-swimmer and swimmer sections of the facility.

20. Failed to establish Zones of Responsibility for lifeguard personnel.

21. Failed to provide and/or require lifeguards to have and use polarized sunglasses.

22. Failed to assess the number of lifeguard personnel required to provide patron surveillance.

23. Failed to provide or require lifeguard personnel to be trained and certified at the Waterfront Lifeguarding certification level.

24. Failed to provide site-specific pre-service training to qualify lifeguard personnel.

25. Failed to provide continuous in-service training of lifeguard personnel.

26. Failed to train lifeguard to differentiate between a report of a missing person versus a missing bather.

27. Failed to implement emergency response plans for a missing bather versus a missing person.

28. Failed to establish Standard Operating Procedures (SOPs) dealing with all operational responsibilities of lifeguard personnel.

29. Failed to develop and implement Emergency Action Plans (EAPs) and to conduct simulated emergency drills to prepare lifeguard personnel for their response to actual emergencies.

30. Failed to develop and implement Emergency Response Plans (ERPs) and to conduct simulated emergency drills to prepare lifeguard personnel for their response to actual emergencies.

31. Failed to conduct emergency drills and to assess lifeguard personnel in their ability to safely, effectively, and rapidly respond to emergency incidents and to develop and appropriate and effective Incident Command structure.

32. Failed to require the use of Personal Flotation Devices (PFDs) by weak or non-swimmers engaged in aquatic recreation activities within the swimmer section of the facility.

33. Failed to require adult supervision within arm’s reach of weak or non-swimmers engaged in aquatic recreation activities within the swimmer section of the facility.

34. Failed to require all lifeguards and supervisors to be trained in lifeguarding and/or CPR/AED for the Professional Rescuer level.

35. Failure to provide and require lifeguard personnel to carry a Personal Resuscitation Mask on their person at all times.

36. Failure to provide and place appropriately-sized Bag-Valve-Mask Resuscitators strategically around the park for use in response to respiratory and/or cardiac emergencies.

37. Failure to provide and place manual hand-held suction devices strategically around the park for use in response to respiratory and/or cardiac emergencies.

38. Failure to provide and place oxygen administration equipment strategically around the park for use in response to respiratory and/or cardiac emergencies.

39. Failure to provide and place Automated External Defibrillators (AEDs) strategically around the park for use in response to cardiac emergencies.

40. Failure to conduct an audit of the park to determine the hazards and risks, as well as to evaluate the operational structure and capability of the lifeguards.

41. Failure to rotate lifeguards in a timely manner and to provide needed breaks throughout their shift.