Failure to Train Staff on LVAD Care and Emergency Response
Penalty
Summary
The facility failed to follow its own facility assessment and did not ensure that staff received in-service and training necessary to provide care for residents with a left ventricular assist device (LVAD). This deficiency affected two residents, both of whom had significant cardiac histories and required specialized care for their LVADs. Interviews with multiple staff members, including RNs, LPNs, and CNAs, revealed that they had not received training on the care or emergency response for residents with LVADs. One RN was unable to demonstrate how to check the LVAD battery capacity and admitted to not checking the LVAD system or batteries during her shift. The Director of Nursing confirmed there was no documentation of staff receiving LVAD training, and the Medical Director stated that at least one nurse per shift should be trained on LVAD care. The facility's assessment tool indicated that LVAD care was among the services offered and that mandatory in-services related to specific diagnoses or equipment, including LVADs, were required. Despite this, several staff members, including those in supervisory roles, reported not receiving any LVAD training, and there was no evidence of hands-on or return demonstration training. The Assistant Director of Nursing, who was identified as the preceptor for LVAD training, expressed that video training alone was insufficient and that hands-on training was necessary. The lack of training and documentation directly contradicted the facility's stated policies and assessment, resulting in staff being unprepared to competently care for residents with LVADs during both routine and emergency situations.