Failure to Ensure Staff Competency and AED Accessibility for Cardiac Emergencies
Penalty
Summary
The facility failed to ensure that nurses and nurse aides had the appropriate competencies to provide emergency services, including use and location of automated external defibrillators (AEDs), despite a resident population with significant cardiac and circulatory conditions. The facility assessment listed common diagnoses such as congestive heart failure, coronary artery disease, angina, dysrhythmia, hypertension, orthostatic hypotension, peripheral vascular disease, risk for bleeding or blood clots, deep venous thrombosis, and pulmonary thrombo-embolism. The facility’s CPR/BLS policy required personnel to be trained in CPR, BLS, and defibrillation for sudden cardiac arrest and directed staff to retrieve an AED and initiate the BLS sequence when an individual was found unresponsive. National Heart, Lung, and Blood Institute information cited in the report identified heart problems, including coronary artery disease, arrhythmias, atrial fibrillation, angina, cardiomyopathy, heart valve disease, and heart failure, as key risk factors for cardiac arrest. During observations, surveyors noted that wall-mounted boxes on two halls were labeled as containing AEDs but were empty. When asked to locate the AED, an RN initially texted an LPN for assistance and the AED was ultimately found stored in an unlabeled lower cabinet in a clean utility room, not in the labeled wall boxes. Multiple nurse aides and an LPN either did not know where the AED was located or incorrectly believed it was in the wall boxes or at the nurses’ stations. Only one nurse aide initially stated she knew the location but was unable to identify it when questioned further. The Nursing Home Administrator and Director of Nursing were informed that staff could not accurately describe the AED locations and confirmed that the facility failed to ensure nursing staff had the competencies and skill sets necessary to provide emergency services, affecting eight of nine sampled staff members.
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