Failure to Maintain 24/7 CPR-Certified Staff Coverage
Penalty
Summary
The facility failed to ensure that at least one CPR-certified staff member was available on-site 24 hours per day, 7 days per week, as required by facility policy. Review of nursing staff schedules and the list of CPR-certified staff revealed multiple shifts, particularly during third shift and weekends, where no CPR-certified staff were present. Both the Administrator and the DON acknowledged gaps in CPR coverage, with the Administrator specifically noting awareness of shortages during certain shifts and the DON confirming ongoing time gaps in coverage. The facility's policy mandates that CPR-certified staff be available at all times, but this standard was not met on several documented occasions. Interviews with facility leadership confirmed knowledge of the deficiency, and documentation showed that the most updated list of CPR-certified staff had not always been communicated. Despite these lapses, there were no reported incidents during the review period where residents required CPR. The facility census at the time was 59 residents, and the deficiency was identified through review of schedules, staff lists, policy, and staff interviews.