Failure to Monitor and Maintain LVAD Results in Resident Death
Penalty
Summary
The facility failed to follow established clinical protocols, manufacturer’s guidance, internal training guidelines, and its own policies and procedures for the care of a resident with a Left Ventricular Assist Device (LVAD). Staff did not monitor or change the LVAD batteries when they reached 50% capacity, as required by policy, resulting in the batteries depleting and the heart pump stopping. The resident was subsequently found unresponsive, sent to the hospital for cardiac arrest, and expired. Multiple staff members on duty during the relevant shifts did not check, change, or ensure the LVAD batteries had adequate voltage, despite having the opportunity and responsibility to do so. The resident involved had a complex medical history, including end-stage heart failure, coronary artery disease, cognitive deficits, and the presence of a heart assist device. Documentation and interviews revealed that staff did not receive adequate training on LVAD care, and several nurses and aides were unfamiliar with the required procedures for monitoring and maintaining the device. The care plan and physician orders lacked specific interventions and monitoring instructions for the LVAD, particularly for the night shift, and there was no comprehensive plan of care developed for the device. Staff interviews confirmed that LVAD checks were not performed as required, and some staff were unaware of how to assess battery status or perform system checks. Facility policy required that LVAD batteries be changed at 50% capacity and that the device be connected to wall power at night. However, staff failed to follow these protocols, and the resident’s LVAD batteries were allowed to fully deplete. Video surveillance and documentation review confirmed that staff did not enter the resident’s room to perform necessary checks during critical periods. The facility’s abuse and neglect policy was not followed, as the failure to provide necessary care and monitoring resulted in neglect, contributing to the resident’s death.
Removal Plan
- In-serviced the Administrator regarding the facility's Abuse/Neglect Policy and Procedure, including neglect.
- Ensured all residents are free from neglect.
- Reported neglect incident to the Illinois Department of Public Health and initiated an investigation.
- Suspended the nurse identified as the alleged perpetrator pending investigation.
- Terminated the nurse from the facility due to failure to provide a clear and accurate report regarding the incident.
- In-serviced facility staff on the neglect/abuse policy and on properly rounding and checking on residents.
- Conducted in-services regarding LVADs and properly checking for batteries and alarms.
- Conducted LVAD training with licensed staff that included ensuring LVADs are connected to the wall outlet to ensure proper battery levels.