Uncertified Staff Provided Supervision and CPR During Choking Event in Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure that personnel supervising residents during meals and providing emergency response were properly certified in CPR/BLS, as required by facility policy. Facility policies on Cardiopulmonary Resuscitation (CPR) and Meal Supervision required that key clinical staff directing resuscitative efforts maintain American Red Cross or American Heart Association BLS/CPR certification, and that nursing staff and designated personnel supervising meals monitor for signs of aspiration or choking and not leave high‑risk residents unsupervised. The Dining Room Supervision standard further required direct observation of high‑risk residents, continuous alertness, and immediate nursing notification if signs of distress were observed. Despite these policies, on the day of the incident only two nurse aides (Employees E12 and E13) were available at the nurse’s station and were the staff present in the dining room when a resident experienced choking. According to the facility’s investigation, Employee E12 provided a lunch tray to Resident R114 in the main dining room. Another nurse aide, Employee E13, observed the resident sitting upright with his tray when he began coughing and raised his hands to his chest. Employee E12 immediately administered back blows and initiated the Heimlich maneuver while calling for assistance, and two nurses then came over and administered CPR, which included the Heimlich maneuver. Review of personnel files showed that both Employee E12 and Employee E13 did not possess valid CPR certification at the time of the incident, and Employee E12 only completed an online CPR course (not from AHA or the American Red Cross) later that same day. Interviews with the DON, Unit Manager, and Administrator confirmed that the two aides assisting in the dining room did not have valid CPR certification at the time of the event and that there should have been at least a nurse in the dining room to supervise residents at risk for aspiration or on aspiration precautions.
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