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F0726
E

Lack of Competency Assessment for Nurses Managing Pleurx Catheters

Pomona, California Survey Completed on 07-17-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that six licensed nurses responsible for the care and management of Pleurx catheters had completed competency assessments to demonstrate their ability to safely handle these devices. Interviews revealed that although in-service training on pleural effusion and Pleurx catheters had been provided, there was no documentation or recollection of formal competency assessments for these nurses. The Director of Staff Development confirmed the absence of such documentation and acknowledged that without competency assessments, there was no verification that staff could properly manage Pleurx catheters. A review of the facility's policies and facility assessment tool indicated that the facility is required to validate staff competencies, especially for specialized care such as catheter management, upon hire and routinely thereafter. The policies also state that training and competency validation should be tailored to the needs of the resident population and any new conditions or procedures. Despite these requirements, the facility did not have evidence that the nurses responsible for Pleurx catheter care had demonstrated the necessary competencies, as required by their own policies and regulatory standards.

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