The compressions weren't deep enough. Nurse 4 and the Staff Development Coordinator watched as Nurse Aide 3's chest compressions failed to create proper recoil, the chest expansion that pushes blood to vital organs. They had to instruct him that his compressions weren't deep enough before switching him out with another staff member.
Emergency Medical Services arrived and placed a backboard under Resident 70 before continuing CPR. The backboard creates the hard surface necessary for effective compressions. Without it, compressions can't achieve adequate recoil or ensure perfusion for vital organs.
Nurse Aide 3 had worked at the facility for only a short time. His CPR certification had expired and was no longer valid. When interviewed by phone, he stated he received no training in medical emergencies, didn't know how to respond, had no idea where emergency equipment was located, and received no CPR training. He also hadn't completed any competencies or skills checks since arriving at the facility.
Nurse Aide 4's training file revealed the same gaps. No orientation on emergency situations, no training on how to respond or what his role should be during emergencies, and no CPR certification. His file contained no job description.
The Staff Development Coordinator had been at the facility for less than a week when the emergency occurred. She explained she hadn't had time to get the training program started but would work on it in the future. When the cardiac arrest happened, she had to ask the Director of Nursing where the crash cart was located.
She received no information about emergency supplies or equipment locations when she started. Nobody told her about code situations, how to run them, or what was supposed to be on the crash cart. Her CPR certification was active and she was trained in advanced life support, but she was operating blind in the facility's emergency procedures.
The Director of Nursing had been at the facility since her hire date but hadn't maintained consistent staff and had no one to oversee the training program. She stated that at bare minimum, staff should receive a facility tour and be shown where crash carts and emergency equipment were located.
When asked for training records for the three nurse aides, Nurse 4, and the Staff Development Coordinator, the Director of Nursing said there were none. She hadn't had a staff member in the training role consistently since she started. Currently, new staff received a quick facility tour and were then sent out with another staff member to be trained.
The Administrator explained that the previous Staff Development Coordinator had started the training program, but when they requested the training materials, she couldn't produce them. They had to part ways with that employee, creating a long-term vacancy.
The facility's orientation overview document indicated that new staff would watch an emergency preparedness video on days one and two. Required paperwork listed CPR cards as required for nurses only but "good to have" for other staff.
The nurse aide job description dated from the facility's records indicated a preference for current CPR certification. The nurse job description required current CPR certification and stated that essential duties included confirming all nursing personnel comply with written policies and verifying all nursing service personnel comply with their job descriptions.
Federal inspectors found immediate jeopardy to resident health and safety. The facility failed to ensure staff were trained in emergency response, how to respond, when to respond, and their role during medical emergencies. They also failed to complete staff competency checklists for medical and clinical emergency responses and equipment locations.
All current residents were at risk as a result of this deficient practice.
The facility's corrective action plan required the Staff Development Coordinator, Director of Nursing, and Unit Manager to ensure all staff complete competency checklists based on their job descriptions for medical emergencies, codes, and equipment locations. Staff would not be allowed to participate in medical emergencies without completing the competency.
Beyond the CPR failures, inspectors found multiple medication safety violations. Medication Aide 2 gave Resident 99 one Prednisone tablet instead of the prescribed three tablets. She also failed to give the resident her Tiotropium bromide inhaler, thinking the resident had the inhaler at her bedside for self-medication. There was no inhaler in the resident's room.
Medication Aide 1 gave Resident 51 one 10-milligram famotidine tablet instead of two tablets to meet the prescribed 20-milligram dose. When shown the bottle she used, she confirmed she hadn't given the resident the correct amount and stated she needed to pay closer attention to the label.
The facility's medication error rate reached 11.11 percent, more than double the federal maximum of 5 percent.
Nurses repeatedly left insulin pens unattended on unlocked medication carts. On one occasion, eight residents' insulin pens sat on top of an unlocked cart in the hallway while the nurse went into a room. Multiple staff and a visitor walked past the unsecured medications.
Expired medications littered both medication rooms. Inspectors found two bottles of bisacodyl that expired in February, melatonin that expired in April, and an opened bottle of omeprazole powder labeled "do not use after" a date that had already passed. A tuberculin vial opened in April carried a May discard date but remained available for use in June.
In the back medication room, a controlled substance box containing 32 lorazepam gel packs was left unlocked. A lorazepam vial sat in an unlocked emergency medication box.
The Medical Director, responsible for implementing resident care policies and coordinating medical care, wasn't familiar with the facility's CPR or emergency response protocols. She told inspectors she had always instructed the facility to call EMS before calling her.
Resident 32, diagnosed with anxiety disorders, bipolar disorder, depression, and schizoaffective disorder, received multiple psychotropic medications without proper monitoring for side effects. Her compound lorazepam gel order lacked a required stop date or indication for use beyond 14 days.
The facility's medication administration records showed no monitoring tools for any of Resident 32's psychotropic medications since her November admission. During inspection visits, she was observed lying in bed sleeping with her breakfast tray in front of her, not easily awakened when her name was called.
Large flies infested multiple resident rooms, landing on beds, pillows, and residents themselves. Room 308 contained open food containers, open beverage containers, and a urinal with dark yellow fluid sitting without a lid on a nightstand. The floor was so sticky it pulled off an inspector's shoe while walking across the room.
The pest control technician found flies in several rooms and noted that some beds and pillows likely had excrement embedded in them, attracting the insects. He recommended replacing mattresses and pillows if possible.
Fly swatters hung on walls next to resident room doors.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Accordius Health At Mooresville from 2024-06-13 including all violations, facility responses, and corrective action plans.
Additional Resources
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