Lack of Staff Competency and Training for VP Shunt Care
Penalty
Summary
Licensed nurses at the facility did not have the specific competencies and skill set necessary to care for a resident with a ventriculoperitoneal (VP) shunt, as identified through the resident's assessment and care plan. The facility's own assessment and training documentation indicated that staff competencies should be based on the clinical characteristics of the resident population, with a curriculum and training plan developed accordingly. However, review of facility education and training materials showed that VP shunt care was not included as a topic for training or competency evaluation. The resident in question had a history of congenital hydrocephalus and a cerebrospinal fluid drainage device, with severe cognitive impairment noted on the most recent assessment. The care plan required nursing staff to pump the VP shunt as directed by the neurosurgeon, but did not include assessment for signs or symptoms of infection or fluid overload related to the shunt. Interviews with nursing staff revealed that training on VP shunt care was informal and limited to being shown how to palpate and pump the shunt, with no formal education on the amount of pressure, rate, or depth of compression, nor on potential complications or necessary assessments beyond monitoring neurological status. Staff were unable to articulate additional assessments or complications related to VP shunt malfunction. The Director of Nursing was unable to provide documentation of training or competency evaluation for VP shunt care and confirmed that no current training was in place for this procedure.