Failure to Ensure Current CPR Certification for Licensed Nursing Staff
Penalty
Summary
The facility failed to ensure that all licensed nursing staff possessed current Basic Life Support (CPR and AED) certifications, as required by facility policy and national standards. Specifically, two nurses, an RN and an LPN, were found to have expired CPR certifications at the time of review. The HR was responsible for checking certifications during onboarding and sent monthly reminders to staff with expired certifications, escalating to the DON after multiple reminders. Despite being aware of the expired certifications, both the HR and DON did not ensure that the certifications were renewed in a timely manner. The DON stated that competencies were reviewed upon hire and annually, but there was no formal competencies policy or checklist in place. Interviews with the DON, HR, and the affected RN revealed that the facility relied on documentation of certification to verify competency, and there was no evidence that either nurse worked shifts without another CPR-certified nurse present. The facility's policy required that CPR-certified staff be available at all times and maintain current certification through an approved provider. However, the lack of current certification for these two nurses represented a failure to comply with the facility's own policy and procedures regarding staff competencies and resident safety.