Failure to Ensure Nurse Competency in LVAD Care Resulted in Harm
Penalty
Summary
Facility staff failed to ensure that all nurses had the appropriate competencies and skill sets to provide adequate nursing care for a resident with a Left Ventricular Assist Device (LVAD). The resident, who had multiple complex medical conditions including chronic systolic heart failure, hypertension, stage 3 chronic kidney disease, diabetes, a history of traumatic brain injury, and a history of subdural hematoma, was re-admitted to the facility with an LVAD in place. Despite the presence of this high-risk device, not all assigned nursing staff were competent in its care and use. On the night of the incident, a nurse accepted responsibility for the care of the resident despite lacking competency in LVAD management. This nurse did not inform other available, competent nursing staff to ensure the resident received proper care. As a result, the LVAD was found disconnected, and the device's alarm had been silenced multiple times. The resident experienced a cardiac event, with a Code Blue called in the morning, CPR initiated, and emergency services contacted. Hospital records indicated that the LVAD was turned off and no CPR was performed for ten minutes prior to EMS arrival, with the resident in asystole and no cardiac activity upon arrival at the emergency department. Interviews with other staff members revealed that some nurses and CNAs had received training and were able to demonstrate or verbalize appropriate LVAD care, but the nurse involved in the incident had not demonstrated competency. Facility documentation and care plans required regular monitoring and documentation of the LVAD, including battery checks and alarm monitoring, but these protocols were not followed by the nurse assigned to the resident, directly resulting in harm.
Removal Plan
- Recorded the incident.
- Obtained statements from involved parties.
- Identified other residents with an LVAD.
- Educated in-house staff on LVAD care.
- Had the LVAD TEAM from the local teaching hospital train staff.
- Initiated audits to ensure ongoing compliance.
- Required all nursing staff to complete LVAD patient care training (training content based on clinical role).