Failure to Ensure Competent Nursing Staff Leads to Medication Error and Inadequate Emergency Response
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies to provide safe and effective care for all residents, resulting in significant medication errors and inadequate emergency response. In one instance, a resident with a tracheostomy and full code status was found unresponsive and pulseless. Staff initiated CPR on a bed without a backboard, contrary to best practices, and failed to provide rescue breaths at the correct rate as outlined in both facility policy and basic life support protocols. The respiratory therapist delegated rescue breaths to another staff member and could not recall who took over, and emergency personnel found that only chest compressions were being performed when they arrived. The Director of Nursing and Respiratory Therapy Director both confirmed that staff actions did not meet expected standards for CPR delivery. Another resident, also with full code status and multiple comorbidities including heart failure and chronic kidney disease, was readmitted to the facility with a medication order for Metolazone to be given three times a week. The order was incorrectly transcribed as three times daily, and this error was not identified during multiple required medication reconciliation checks by several nurses and the Assistant Director of Nursing. The pharmacy questioned the order, but the nurse responsible failed to verify it with the provider as instructed. The resident received seven doses of Metolazone in three days, and the error was not caught by the provider during a subsequent review. After the error was discovered, new orders were given, including obtaining orthostatic vital signs, but these were not completed before the resident was found unresponsive on the floor with severe hypotension and subsequently died. Additionally, when the second resident was found unresponsive after a fall, staff failed to properly assess and intervene as the resident's condition deteriorated. Despite the resident being face down, unresponsive, and bleeding, staff did not reposition the resident to assess airway or breathing, nor did they initiate CPR or other life-saving measures as the resident's respiratory rate declined. Staff cited facility policy as the reason for not moving the resident, but both the physician and Director of Nursing stated that staff should have stabilized and repositioned the resident to allow for proper assessment and intervention. These failures in medication management, emergency assessment, and CPR delivery demonstrate a lack of sufficient nursing staff with appropriate skill sets, directly impacting resident safety and well-being.