Lack of Staff Training on Life Vest Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies and skills to care for a resident with a Life Vest, a wearable defibrillator designed to protect against sudden cardiac death. This deficiency was identified through a review of the manufacturer's guidelines, facility policy, clinical records, and staff interviews. The deficiency placed one resident, identified as Resident R811, in immediate jeopardy, impacting their health and safety. Resident R811 was admitted to the facility with a Life Vest, as indicated in their clinical records. The resident had a history of alcoholic cardiomyopathy, sarcoidosis of the lung, and depression. Despite the presence of a physician's order to check the Life Vest placement and battery daily, the resident's care plan did not include any problem, goal, or interventions for the care and management of the Life Vest. Interviews with the resident and various staff members revealed a lack of training and understanding regarding the Life Vest, with staff members admitting they had not received training on its use. Observations and interviews further highlighted the facility's failure to provide adequate training to its staff. Several staff members, including nurse aides and registered nurses, confirmed they had not been trained on the Life Vest at the facility. This lack of training and understanding among the staff led to a situation where the resident was managing the Life Vest independently, including changing the battery, which should have been part of the staff's responsibilities. The facility's inaction in ensuring staff competency in handling the Life Vest directly contributed to the deficiency and the immediate jeopardy situation for Resident R811.
Plan Of Correction
1. Care plan and physician orders for care of life vest for R811 were updated. 2. An audit was done of residents requiring life vest in facility; there were none. 3. Admissions director was in-serviced by director of nursing on notifying nursing administration of any admissions to facility requiring life vest prior to admission. Director of nursing will in-service nursing leadership on identifying and reporting educational needs for equipment or procedures to nursing administration. Nursing staff were educated on care of the life vest, including how the life vest works, what audible alerts mean, cleaning of the vest, and removing for hygiene. Facility has contracted with Core Tactics for onsite in-service training to occur on 3/11/2025 and 3/12/2025 for use and care of resident with life vest. 4. Director of nursing or designee will audit new admissions for 30 days to ensure residents with special equipment needs are communicated to the nursing department and needed education is provided. Audit results will be shared with QAPI.
Removal Plan
- Facility will implement immediate education for nursing staff for care and operation of the Life Vest, to include what alerts mean, first responder instructions, emergency patient management, showering and laundering of vest. All additional staff will be in-serviced on care and operation of the Life Vest prior to the next shift worked. Any staff not scheduled will be contacted via telephone and educated prior to the next scheduled shift.
- Resident R811's care plan will be revised to include use of the Life Vest. Physician orders for R811 will be reviewed to ensure orders for care and operation of the Life Vest are present and being followed.
- The NHA and DON will review the policy and procedure for use of the Life Vest to be revised as necessary. Policy for ensuring equipment needs on new admissions will be reviewed and revised to include communication of equipment needs by admissions staff to nursing staff prior to admission. Admissions director will be re-inserviced on communicating equipment needs to nursing department. Education needs regarding use of equipment will be assessed and provided prior to use.
- The NHA will audit all new admissions to ensure all equipment needs for new admissions are being met and staff are educated on equipment prior to use. Education, policy revision, and ongoing audits will be shared with Quality Assurance and Performance Improvement (QAPI) committee.