Failure to Ensure Nurse CPR Competency and Certification
Penalty
Summary
The facility failed to ensure that a nurse assigned to care for a resident with full code status was competent and certified to perform Cardiopulmonary Resuscitation (CPR) at the time of an emergency. The resident, who had severely impaired cognition and was unable to participate in a mental status exam, was found unresponsive and without a pulse. The nurse on duty initiated CPR and called 911, but it was later determined by emergency responders that the resident may have expired about an hour prior to their arrival. Review of records showed that the nurse's CPR certification had expired six months before the incident, and there was no documentation of completion of the required annual CPR competency. Interviews revealed that the Director of Nursing (DON) was unaware of the nurse's expired certification and acknowledged that the facility had not conducted any mock code drills in the past year, contrary to their stated policy. The DON also indicated that responsibility for tracking staff competencies and CPR recertification had lapsed due to recent staff departures in both the staff development and human resources departments. An audit conducted during the survey identified another nurse with an expired CPR certification. The Medical Director stated that it is expected for both the facility and individual nurses to ensure timely renewal of CPR certifications.