Inaccurate Documentation of Refrigerator/Freezer Temperature Logs
Summary
The facility failed to ensure the accuracy of documentation for refrigerator/freezer temperature logs in two dietary pantries. Observations revealed incomplete temperature logs with blank spaces for multiple dates in April 2024. Specifically, the [NAME] Dietary Pantry had missing entries from 04/05/24 to 04/14/24 and 04/16/24 to 04/21/24, while the East Dietary Pantry had missing entries on 04/06/24, 04/12/24, 04/13/24, 04/17/24, 04/18/24, and 04/19/24. Photographic evidence was obtained to support these findings. Subsequent observations showed that the logs were later fully completed with no blank spaces, indicating that the entries were filled in after the initial observation. During an interview, the DON confirmed that the nursing staff was responsible for completing the temperature logs daily. The DON reviewed the photographic evidence and acknowledged that the logs should not have been retroactively completed. The facility's policy on employee conduct emphasizes the importance of honest communication and adherence to professional standards, which was not followed in this instance. The nursing staff's failure to complete the logs daily and the subsequent filling in of blank spaces led to the deficiency.
Penalty
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A CNA with a recent conviction for domestic violence, a disqualifying offense under state law, continued to provide direct care to all residents after the conviction. Facility leadership was aware of the conviction but allowed the CNA to work, citing personal character standards, despite not meeting the required time elapsed since probation discharge. This action was not in compliance with state regulations or facility policy.
Failure to Remove CNA Convicted of Disqualifying Offense
Penalty
Summary
The facility failed to ensure that a Certified Nurse Aide (CNA) who had been convicted of a disqualifying offense, specifically first-degree misdemeanor domestic violence, did not continue to provide direct care to residents. Personnel records, background check logs, and court documents confirmed that the CNA was arrested and later convicted of domestic violence. Despite this conviction, which is listed as a disqualifying offense under Ohio Administrative Code, the CNA continued to work in the facility and provide direct care to residents. The review of staff schedules showed that the CNA worked multiple shifts after the conviction date, while still on probation for the offense. Interviews with the Human Resources Director and the interim Administrator revealed that both were aware of the conviction but allowed the CNA to continue employment, citing the use of personal character standards. However, the CNA did not meet the specific requirement that at least five years must have elapsed since being fully discharged from probation for an offense of violence, as outlined in the relevant state regulations. Facility policy and the staff handbook clearly state that conviction of a relevant criminal offense may result in termination, and that staff are responsible for reporting such convictions. The facility's own documentation and interviews confirmed that the CNA's continued employment was not in compliance with state law or facility policy, as the CNA had access to all residents during this period despite the disqualifying conviction.
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