Failure to Provide Comprehensive Staff Training on Cold Therapy Device
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for staff regarding the use of a cold therapy device, specifically the Breg Polar Care Cube, for a resident who was admitted after a right shoulder replacement. The manufacturer's instructions for the device require specific procedures for safe use, including regular skin inspections and ensuring the device is not run without water. However, the only information posted in the resident's room pertained to general post-operative care and did not include instructions on the use or care of the cold therapy machine. Interviews and documentation revealed that the use of cold therapy machines was not common in the facility, and education on the device was inconsistently provided. While some nurse aides and therapy staff received instruction on the device, this education was not extended to all staff assigned to the resident's care, particularly those on afternoon and evening shifts. Staff members confirmed that not all personnel were trained, and some had never previously cared for a patient using such a device. The deficiency was further substantiated by the resident's own report that staff seemed unaware of how to use the cold therapy machine, and by the facility's own admission that an effective training program, including additional topics based on the resident population and non-common procedures, was not in place. Facility records showed that only a subset of staff received education on the device, despite multiple staff being assigned to the resident's unit during the relevant period.