An LPN failed to demonstrate CPR competency and did not follow code procedures for a full-code resident with dementia, DM, CKD, and HF. After being told the resident was not breathing, the LPN began CPR without calling a Code Blue, stopped CPR to get a CNA to witness and help clean up the resident, then resumed CPR. The CNA said they were not told to call 911 or initiate a Code Blue, other staff were unaware CPR was occurring, the crash cart was not accessed, and the PCP and DON stated the expected process was not followed. The LPN had no CPR training documented.
Failure to Verify and Honor DNR Before CPR: Staff initiated CPR on a resident with a documented DNR after the resident was found unresponsive. A CNA alerted an LPN that the resident was not feeling well, and when the resident was later found without respirations or a pulse, CPR was started before the code status was checked. Interviews showed staff were supposed to verify code status in the EMR before beginning CPR, but the LPN and other staff did not confirm the DNR first, and CPR continued until EMS arrived.
A resident with full code status was found unresponsive without respirations or pulse during the night shift. An RN and an LPN initiated CPR but did not activate EMS, and they discontinued CPR after about 20 minutes. The RN, who lacked documented orientation and competency assessment and had obtained BLS certification through a fully online, non–instructor-led course, pronounced the resident deceased without authority and later stated she believed the resident was on hospice and did not verify code status. The LPN’s BLS certification was expired, and a CNA with an expired BLS certification performed several chest compressions despite facility policy that CNAs were not to perform CPR. The RN had not participated in documented code blue drills, and leadership confirmed that required clinical orientation and skills competencies had not been completed for her, leading surveyors to determine that staff were not adequately trained or competent to respond to a cardiopulmonary arrest for a full code resident, resulting in an Immediate Jeopardy finding.
Incompetent Use of Sit-to-Stand Lift During Resident Transfer: A CNA transferred a resident using a sit-to-stand lift without securing the lower leg straps and without another staff member assisting. The resident slid from the lift during transport and sustained a femur fracture and shoulder dislocation. Record review and staff interviews showed orientation and competency documentation did not specify training on the specific lift model or confirm return-demonstration competency, and staff reported differing familiarity with the facility's lift types.
A resident with full code status was found in cardiac and respiratory arrest, and an RN and an LPN initiated CPR but did not activate EMS as required by policy. After about 20 minutes, the RN unilaterally stopped CPR, effectively pronounced death without authority, and did not verify the resident’s code status, later stating she believed the resident was on hospice. EMS was not called until approximately four hours later, when CPR was briefly restarted and a CNA was directed to perform chest compressions. The investigation found that the RN had no documented orientation or skills competency assessment, her BLS/CPR training was fully online without hands-on instruction, and both the LPN’s and CNA’s BLS/CPR certifications were expired, demonstrating a broader failure to ensure staff CPR competency and proper emergency response.
The facility failed to ensure that nursing staff had verified competencies for IV therapy and tracheostomy care. HR records showed most LPN IV certifications as expired or undocumented, yet LPNs administered multiple IV antibiotic and flush doses to two residents without documented IV competency. Two residents with tracheostomies were observed with undated oxygen and trach tubing, missing or inaccessible emergency trach supplies, and visible secretions, while staff could not locate required physician orders for humidified oxygen or trach care details. Documentation on treatment records showed missed or unrecorded trach tie changes, suctioning, and dressing changes, and HR and the DON could not provide evidence of completed trach care competency assessments for nursing staff, despite a facility policy requiring ordered, individualized trach care.
The facility failed to ensure that nursing staff had appropriate IV therapy competencies, resulting in non-certified LPNs administering and managing IV medications and lines for two residents receiving treatment for cellulitis, infection, and related conditions. Physician orders included midline and PICC insertion, IV antibiotics, saline flushes, and PICC/midline monitoring, all of which were documented as performed by LPNs without verified IV certification. Leadership and medical staff interviews revealed conflicting understandings of LPN IV scope, with the NHA stating certification was not required for most IV tasks, while the DON, ADON, Medical Director, and Attending Physician stated that LPNs must be IV certified to administer, monitor, or maintain IV/PICC lines. Orientation processes did not include collection or verification of IV certifications, and personnel files for involved LPNs lacked documentation of IV certification despite facility policy and job descriptions referencing the need for advanced IV training and compliance with state IV therapy requirements.
Uncertified LPNs administered IV Meropenem to two residents with serious infections and orthopedic complications. Facility policy and the DON and ADON stated that only an RN or IV-certified LPN could give IV meds, but the facility could not produce IV certification documentation for the LPNs who gave the doses.
Improper Medication Administration by LPN: An LPN prepared a resident’s crushed scheduled medications and poured them into the resident’s breakfast, then left the room while a CNA continued feeding the resident. The LPN later acknowledged the CNA was administering the medication outside scope of practice and that the nurse should have remained with the resident during administration. The DON verified that CNAs were not trained or qualified to administer medications and that the facility’s procedure required the nurse who prepared the medication to administer it.
A resident with a documented full code status was found unresponsive and without vital signs, but multiple staff, including CNAs, an LPN, and RNs, failed to initiate CPR or call a code blue. The assigned CNA and another CNA reported that the LPN delayed responding, obtained an oxygen saturation of 60, left to verify code status, confirmed the resident was full code, yet did not start compressions or call a code, and no staff performed CPR before EMS arrived. The LPN later stated she believed the resident was already dead, did not call a code, did not ask CNAs for help to move the resident or use a backboard, and acknowledged that no interventions were performed while they waited for EMS. Other nurses who came to the room assumed the resident was a DNR based on how the situation was presented, did not independently verify code status, did not initiate CPR, and did not call a code blue. EMS questioned why CPR had not been started for a full code resident, and the medical director confirmed that facility expectations and protocol required immediate CPR for an unresponsive full code resident and did not authorize nurses to pronounce death.
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