Failure to Investigate and Monitor Adverse Event Following Resident Death
Penalty
Summary
The facility failed to implement effective adverse event monitoring and investigation processes, specifically in the case of a resident with chronic kidney disease, hypertension, and type 2 diabetes who was a full code. The resident, who had severely impaired cognition and could not participate in mental status exams, was found unresponsive and pulseless. The nurse on duty, whose CPR certification had expired six months prior, left the resident with a certified nursing aide to call 911, initiate a code blue, and retrieve the crash cart before starting CPR. Emergency responders later determined the resident may have expired about an hour before being found. The Director of Nursing (DON) was unaware that the nurse's CPR certification was expired and stated that responsibility for tracking certifications belonged to the Staff Development Coordinator and Human Resources, both of whom had recently left the facility. The DON had assumed their duties but had not yet filled the positions. Although a code sheet system was reportedly implemented to document code events, the sheet was not completed for this incident, and the DON did not conduct an investigation, stating that nothing in the medical record warranted further review. The DON was also unaware that CPR was not initiated immediately. The Administrator confirmed that the facility's process for unexpected deaths of full code residents included completing a code sheet and review by the DON and physician, but this was not done in this case. The Medical Director expected all staff to be recertified in CPR every two years and was notified of the incident, noting the death was not expected as the resident was not on hospice. During a facility-wide audit conducted during the survey, another staff member was found to have an expired CPR certification.