Inadequate Competency of LVN Leads to Delayed Emergency Response
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN) from a Nursing Registry demonstrated the necessary competency to provide adequate care for a resident. The resident, who was admitted with chronic obstructive pulmonary disease, respiratory failure, and generalized anxiety disorder, experienced chest pain and difficulty breathing. Despite the resident's emergency contact requesting a transfer to the hospital, the LVN did not take immediate action, citing a lack of awareness of the facility's protocol and inability to reach the Director of Nursing (DON) or Administrator for guidance. The LVN, who was the only licensed nurse on duty, assessed the resident and determined there was no distress, despite the resident's complaints. The LVN attempted to have the resident sign an Against Medical Advice (AMA) form, which was refused. It was not until the resident reported chest pain again that the LVN called 911, resulting in a delayed transfer to the hospital. Interviews with the emergency contact and the resident confirmed the resident's distress and the LVN's inaction. Further investigation revealed that the LVN had not completed the facility's nursing competency checklist prior to working at the facility, and there was no documentation of such. The DON confirmed the absence of a policy and procedure for staffing competency and acknowledged that the LVN did not create an SBAR, which is a standard practice at the facility. This lack of competency assessment and documentation contributed to the deficiency in care provided to the resident.
Penalty
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Staff failed to follow and competently implement the LOA process, allowing a cognitively impaired, functionally dependent resident with multiple comorbidities to leave with a cousin for several days without the knowledge of nursing staff or family. A CNA who had not been trained on LOA assisted the resident in leaving, and an LPN relied on second-hand information that the resident would return later that evening, without confirming or documenting the required LOA details or medications. The resident did not return as expected, and his absence was only recognized the next day when an LPN noted missed medications and contacted the resident’s daughter, who reported that the family had not taken him. The facility’s LOA policy requirements for nurse notification, estimated time of return, medication provision, and documentation were not met, and no required report of the incident was submitted to the state agency.
A nurse without demonstrated competency in LVAD care accepted responsibility for a resident with an LVAD, failed to follow required protocols, and did not notify other competent staff. This led to the LVAD being disconnected, alarms being silenced, and a delayed response to a cardiac event, resulting in harm to the resident. Other staff interviewed were able to demonstrate or verbalize appropriate LVAD care, but the assigned nurse did not meet competency requirements.
The facility did not ensure that several agency CNAs had documentation of required training in abuse and neglect, dementia, resident rights, infection control, communication, and behavioral health. Administrative and staffing staff confirmed that the necessary records were not available, and the facility assessment had outlined these training requirements for all CNAs.
A CNA who had not been checked off for competency in using a mechanical lift participated in transferring a resident who was fully dependent for transfers. The sling was not positioned correctly, and the resident slid out and fell to the floor. Facility policy required demonstration and validation of competency before operating such equipment, but this was not followed in this case.
The facility did not ensure that licensed nursing staff completed the necessary competency training to care for residents. A review showed that nine out of 19 staff members lacked required training. The HR Director could not provide evidence of completed training, and the Administrator was informed of the issue.
Failure to Ensure Competent LOA Process Resulting in Unmonitored Resident Absence
Penalty
Summary
Facility staff failed to maintain competency in the nursing aide proficiency related to leaves of absence (LOA), resulting in a resident leaving the facility for approximately three days without the knowledge of family or nursing staff. The resident involved had a history of stroke, hypertension, chronic systolic heart failure, left-sided hemiparesis, and aphasia, and had a BIMS score of 7/15 indicating moderate cognitive impairment. He required assistance with all activities of daily living and, prior to the incident, was his own decision maker, as the power of attorney (POA) documents were not executed until after his return. On the day of the incident, the resident left the facility at approximately 2:00 p.m. with a person identified as a cousin, who signed the resident out on the facility’s LOA sign-out sheet. CNA staff assisted the resident in leaving, despite not having been trained on the LOA process. The Manager on Duty observed the resident leaving with the family member and was told by both the cousin and the resident that he had been signed out and would be going to a cookout and returning later that evening. LPN staff were informed, via another CNA, that the resident would return around 7:00 p.m., and this information was passed in shift report, but no further verification or follow-up occurred when the resident did not return as expected. The facility’s LOA policy required that the patient or responsible party notify a licensed nurse prior to leaving, provide an estimated time of return, receive medications, and have the LOA documented in the medical record, with additional notification to administrative staff if the resident would not return the same day. In this case, the resident left with a family member without medications and without a documented plan consistent with policy requirements. The resident’s departure was not recognized as a problem until the following day when an LPN noted that he had not returned to receive medications and contacted the resident’s daughter, who reported that the family had not removed him and was unaware of his whereabouts. No initial or 5‑day follow‑up report of the incident was submitted by the facility to the state agency as required by law.
Failure to Ensure Nurse Competency in LVAD Care Resulted in Harm
Penalty
Summary
Facility staff failed to ensure that all nurses had the appropriate competencies and skill sets to provide adequate nursing care for a resident with a Left Ventricular Assist Device (LVAD). The resident, who had multiple complex medical conditions including chronic systolic heart failure, hypertension, stage 3 chronic kidney disease, diabetes, a history of traumatic brain injury, and a history of subdural hematoma, was re-admitted to the facility with an LVAD in place. Despite the presence of this high-risk device, not all assigned nursing staff were competent in its care and use. On the night of the incident, a nurse accepted responsibility for the care of the resident despite lacking competency in LVAD management. This nurse did not inform other available, competent nursing staff to ensure the resident received proper care. As a result, the LVAD was found disconnected, and the device's alarm had been silenced multiple times. The resident experienced a cardiac event, with a Code Blue called in the morning, CPR initiated, and emergency services contacted. Hospital records indicated that the LVAD was turned off and no CPR was performed for ten minutes prior to EMS arrival, with the resident in asystole and no cardiac activity upon arrival at the emergency department. Interviews with other staff members revealed that some nurses and CNAs had received training and were able to demonstrate or verbalize appropriate LVAD care, but the nurse involved in the incident had not demonstrated competency. Facility documentation and care plans required regular monitoring and documentation of the LVAD, including battery checks and alarm monitoring, but these protocols were not followed by the nurse assigned to the resident, directly resulting in harm.
Removal Plan
- Recorded the incident.
- Obtained statements from involved parties.
- Identified other residents with an LVAD.
- Educated in-house staff on LVAD care.
- Had the LVAD TEAM from the local teaching hospital train staff.
- Initiated audits to ensure ongoing compliance.
- Required all nursing staff to complete LVAD patient care training (training content based on clinical role).
Missing Required Training Documentation for Agency CNAs
Penalty
Summary
Facility staff failed to ensure that four out of ten reviewed certified nursing assistant (CNA) records included documentation of required training in abuse and neglect, dementia, resident rights, infection control, communication, and/or behavioral health. Specifically, several agency CNA files lacked evidence of education in these areas, with one file missing entirely. The review process included examination of both facility and agency CNA records, and interviews with administrative and staffing personnel confirmed that the required documentation was not available. The staffing coordinator stated that agency staff files typically included only licenses, background checks, sworn disclosures, and CPR certifications, and that the facility relied on agencies to provide additional training documentation, which was not always received. The facility assessment, last reviewed prior to the survey, outlined the necessity for staff training in communication, resident rights, abuse and neglect, dementia care, and infection control, as well as the requirement for at least 12 hours of in-service training per year for CNAs. Despite these requirements, the facility was unable to provide evidence that all agency CNAs had completed the mandated training. The staff educator was unavailable during the survey, and administrative staff acknowledged that the files provided were all that were available at the time.
CNA Operated Mechanical Lift Without Demonstrated Competency, Resulting in Resident Fall
Penalty
Summary
Facility staff failed to ensure that a certified nursing assistant (CNA) had demonstrated competency in the use of a mechanical lift prior to operating it with a resident who was completely dependent on staff for transfers. The CNA in question, who was still in orientation and had not been checked off for safe use of the Hoyer lift, participated in transferring a resident using the lift. The resident was cognitively intact but physically dependent, requiring full assistance for transfers. During the transfer, the CNA operated the lift remote while another CNA assisted with securing the sling. The sling was not positioned correctly under the resident's lower body, and the resident subsequently slid out of the sling and fell to the floor. Interviews with staff and the resident confirmed that the CNA operating the lift had not been signed off for competency, and the improper sling positioning contributed to the fall. The resident reported that the sling was not placed all the way down to her knees and described jerking motions during the transfer, which led to her slipping out. Facility policy required that CNAs demonstrate competency in mechanical lift use before operating such equipment, with documentation and validation by a nursing trainer or staff development coordinator. Despite this policy, the CNA was allowed to participate in the transfer without having completed the required competency check, directly leading to the incident.
Failure to Ensure Nursing Staff Competency
Penalty
Summary
The facility failed to ensure that licensed nursing staff completed the required competencies necessary to care for residents' needs. A review of the training transcripts for 19 licensed staff members revealed that nine of them did not complete the required training courses. During an interview, the Human Resource Director was unable to provide evidence that these nine staff members had completed the necessary competency training. The Administrator was informed of these concerns during the end-of-day meeting on June 13, 2024.
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