Failure to Maintain Sufficient Competent Staff and Emergency Response Procedures
Penalty
Summary
The facility failed to maintain sufficient levels of competent staff to ensure residents received the care needed to maintain the highest quality of life. Two residents were directly affected, with six others at risk, due to inadequate staffing and lack of proper emergency response procedures. In one case, a resident with multiple complex medical conditions, including diabetes, COPD, schizophrenia, and dependence on supplemental oxygen, experienced a significant drop in oxygen saturation. The nurse on duty administered inhalers and BiPAP, but the resident's oxygen levels remained below normal. There was no evidence that the physician was notified or that adequate interventions were taken. When the resident was later found unresponsive, CPR was initiated, but there was a delay in calling 911 due to staff confusion and lack of familiarity with the facility's emergency procedures and equipment. The resident was ultimately pronounced dead at the hospital. In another incident, a resident with a history of pneumonia, COPD, diabetes, CHF, and severe cognitive impairment became short of breath and requested assistance. The nurse provided inhalers and attempted to obtain oxygen equipment from another floor, leaving the resident unattended. Upon return, the resident was found unresponsive. The nurse had to leave the floor again to seek help, as there was no immediate way to call for assistance. CPR was started without checking for a pulse, and the facility lacked an AED. The resident was transported to the hospital and later pronounced deceased. Staff interviews revealed that nurses and aides were often responsible for residents on multiple floors, and there was confusion about emergency protocols, including the existence of a code team and the use of code blue documentation. Observations and interviews further indicated that staff were not consistently present on the first-floor unit, and some staff were not CPR certified or aware of emergency response roles. The facility's assessment stated that staff training and competencies were to be maintained, but interviews with staff and review of records showed gaps in training, orientation, and emergency preparedness. The lack of clear procedures, insufficient staffing, and inadequate training contributed to delays and errors in emergency response, directly impacting resident care and outcomes.