Failure to Follow LVAD Emergency Protocols Resulting in Resident Death
Penalty
Summary
The facility failed to provide appropriate, person-centered care and treatment for a resident with a Left Ventricular Assist Device (LVAD), resulting in a critical incident. The resident, who had multiple complex medical diagnoses including heart failure, diabetes, and cognitive deficits, was found unresponsive. Staff did not follow the facility's emergency response protocol for LVAD management, which required checking the device for functioning and battery status during emergencies. Instead, staff initiated CPR without assessing the LVAD, and none of the responding nurses or CNAs checked whether the device was operational or if the batteries were charged. Interviews with staff revealed that none of the personnel involved in the emergency response had received training on LVAD emergency procedures. Several staff members admitted to not checking the LVAD or its batteries, and some were unaware of the specific steps required to manage an LVAD during a code situation. The Director of Nursing confirmed there was no documentation of LVAD training for staff, and the Assistant Director of Nursing stated that hands-on training was not provided. The facility's own policy required immediate assessment of the LVAD's function and battery status during emergencies, but this was not followed. Medical records and device logs indicated that the LVAD batteries had been depleted for an extended period prior to the resident being found unresponsive, and the device had stopped functioning, contributing to cardiac arrest and subsequent death. The lack of individualized care planning for the resident's full code status and LVAD management further contributed to the deficiency. The failure to follow established protocols and provide necessary staff training directly led to the adverse outcome.
Removal Plan
- Regional Nurse Consultant in-serviced the Director of Nursing regarding the facility's Emergency Protocol and Procedure for a resident with an LVAD.
- The Director of Nursing and Nurse Managers completed education with nurses on the facility's Emergency Protocol and Procedure for a resident with an LVAD.
- The Director of Nursing and Nurse Managers completed the education provided by the manufacturer to the facility nurses.
- The Director of Nursing was in-serviced by the Regional Nurse Consultant regarding emergency response for LVAD system and specialized device care.
- The Director of Nursing provided education to licensed and unlicensed nursing personnel on emergency response for LVAD system.
- The emergency response procedure will be placed in the resident care plan and at the bedside.
- The Director of Nursing and/or Nurse Managers will provide education to current nursing department staff with competency exams when facility admits any specialty care resident specifically LVAD.
- This process will be included in the new hire onboarding/orientation process.
- The facility nurses will also receive training competencies for staff caring for residents with specialty care needs.
- The facility has revised its staffing protocols to ensure that at least one staff member trained in LVAD management is always on duty when there is an LVAD in the facility.
- The schedule is now maintained to verify proper coverage and trained staff assigned are being routinely audited by DON/designee.
- The Director of Nursing and/or designee has educated licensed nursing staff on recognizing and appropriately responding to LVAD-related emergencies including prioritization of device functions assessment during a code situation.
- Mock code drills incorporating LVAD scenarios will be conducted with documentation and debriefing to reinforce staff knowledge and readiness.