F0940

G

Failure to Ensure Effective Orientation and Emergency Transfer Training for Newly Hired RN

Bridgman, Michigan Survey Completed on 01-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide and monitor an effective training program for a newly hired RN, specifically related to emergency procedures and hospital transfers, which contributed to a delayed response to a resident’s acute change in condition and emergent transfer. The facility’s DON and NHA stated that new nurses receive five days of training and an orientation checklist that includes emergency procedures, hospitalization, transfer forms, and emergency access for rapid transport. However, the DON acknowledged that the checklist does not have to be completed before being returned and that the orientation checklist for the involved RN had not been turned in, leaving the DON unaware of which training items had been completed. The orientation checklist for this RN was not provided to surveyors by the time of exit.

The newly hired RN reported that she started at the end of the prior month and had not completed all of her training, including training on transferring a resident to an acute care hospital. On the night in question, she had to transfer two residents to the hospital for changes in condition and stated she had never done this before. She reported that another RN was assisting her with the orientation training checklist and with completing the paperwork, steps, and packet required for a hospital transfer. The assisting RN confirmed that the new RN appeared overwhelmed and unfamiliar with the transfer process and that she tried to help with the required paperwork. The new RN stated that she asked whether they should just call 911 for the resident and was told by the assisting RN to finish the paperwork while the assisting RN went to eat and would help again afterward.

During this same shift, EMS and 911 records show multiple calls associated with the facility and a delay in EMS activation for the resident who was ultimately found unresponsive. 911 records documented an abandoned call from the facility, a return call from 911 during which facility staff reported no emergency, and subsequent calls from the local emergency department and ambulance service indicating that the hospital had received report on a patient from the facility but had not yet received the patient. EMS documentation for the resident later transported described dispatch for a cardiac or respiratory arrest, arrival to find the resident unconscious, minimally responsive, hypoxic, and requiring escalating oxygen support and eventual transfer to the emergency department. Hospital records documented that the resident, an older adult with dementia with psychotic features, major depressive disorder, and atrial fibrillation on Eliquis, was brought in unresponsive, hypotensive, tachycardic, cool, and cyanotic, and was intubated for airway protection. The combination of incomplete orientation, lack of verified competency in emergency transfer procedures, and the facility’s failure to ensure the new RN was effectively trained and monitored in these processes led to a delay in treatment and emergent hospital transfer for this resident.

The DON confirmed that she did not know which emergency procedure and transfer-related training items the new RN had completed because the orientation checklist had not been returned. The Licensed Nurse Orientation and Skill Check form included items such as emergency procedures, hospitalization, transfer form from the electronic record, and emergency access for rapid transport, but there was no evidence these competencies had been completed or validated for the new RN. The new RN’s own statements that she had never transferred a resident to the hospital before, had not yet completed all of her training, and did not complete the first transfer’s paperwork correctly further demonstrate that the facility did not maintain an effective training and monitoring process for new nurses in critical emergency and transfer procedures, contributing to the deficient practice identified by surveyors.