Failure to Ensure Staff Competency and Proper Resident Transfers
Summary
The facility failed to ensure that all nursing staff, including agency staff, received proper orientation and competency verification before providing care to residents. Specifically, Nurse Aide (NA) #1 transferred a resident using a sit-to-stand mechanical lift, contrary to the resident's care plan, which required a total mechanical lift with two-person assistance. This improper transfer resulted in the resident's foot slipping, causing the resident to be lowered to the floor and subsequently lifted manually by NA #1 and NA #2 without using the appropriate mechanical lift. The resident later suffered an acute fracture of the left hip, underwent surgery, and was eventually discharged to hospice care, where they expired shortly after. The incident highlights a significant lapse in ensuring that staff were adequately trained and aware of the resident's specific care requirements as outlined in their care plan and Kardex system. The competency checklist for NA #1 from the agency indicated previous training and experience in patient transfers but lacked specific information on using mechanical lifts. NA #1 admitted to not receiving orientation or education on resident transfers or lift equipment from the facility and was unaware of how to access resident care plans or the Kardex system. NA #2, who assisted NA #1, also did not provide proper guidance on the required transfer method for the resident. The Director of Nursing (DON) and the Scheduler failed to verify NA #1's competency in using mechanical lifts before allowing her to provide care, relying instead on a general skills checklist from the staffing agency. Interviews with various staff members, including the DON, Scheduler, and other nurses, revealed a lack of consistent orientation and competency verification for agency staff. The DON acknowledged that agency staff were given only basic resident care information and were expected to seek guidance from nursing staff if needed. The Administrator admitted that the incident was avoidable if the staff had followed the care plan, indicating a systemic issue in ensuring that all staff, including agency staff, were adequately trained and aware of the specific care needs of residents. This deficiency in staff training and competency verification directly led to the resident's fall and subsequent injury.
Removal Plan
- Director of Nursing and/or their designee completed education with facility licensed nurses and C.N.A.'s on lift competency with return demonstration. Licensed agency nurses and C.N.A.'s were educated on proper lift competency with return demonstration. Education was also provided on where licensed nurses and C.N.A.'s can locate current lift status.
- Director of Nursing and/or their designee educated all licensed nurses and C.N.A.'s, including agency staff on location of resident care guides.
- All new facility licensed nurses and C.N.A.'s will receive education from the unit managers on the location of the resident care guides during their orientation. Unit Managers were notified of this responsibility.
- All licensed nurses and C.N.A.'s from an agency are required to come in prior to their first shift to receive lift training and review facility policies. This training is completed by the Director of Nursing and/or their designee. The nursing scheduler is responsible for scheduling agency staff for this orientation. The nursing scheduler notified the agencies of this requirement. Each agency staff is now required to read through facility policies and procedures related to resident care which are located at each nurse's station in the Agency Orientation book. They are to acknowledge understanding of these policies by signing the Policy Acknowledgement Sheet. Agency staff are required to complete lift competency prior to working, this is completed by the Director of Nursing and/or their designee. The facility is requiring the agency to provide the skills checklist of each agency staff member for review prior to working. The Director of Nursing and/or their designee will review the skills check list to ensure that they have the skills to meet the needs of our residents.
- The Director of Nursing and/or their designee completed lift competencies with return demonstration for all licensed nurses and C.N.A.'s and agency staff.
- New hires will be educated Director of Nursing and/or designee on facility policies and lift competencies upon hire.
- The facility made the decision to have an ad hoc QAPI (Quality Assurance and Process Improvement) committee meeting as a result of our investigation into the incident. It was the decision of the QAPI committee to begin monitoring of this deficient practice for a period of 12 weeks.
- The Director of Nursing and/or their designee will audit five (5) agency staff, licensed staff and C.N.A.'s, to the location of the care guides for the residents.
- The Director of Nursing and/or their designee will audit five (5) facility and agency C.N.A.'s weekly for 12 weeks observing lift transfers. Any negative observations will be corrected immediately.
- Results of the audits will be presented monthly to the QAPI committee meeting by the Director of Nursing and or their designee for review and/or revision as needed for three (3) months.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Insulin Pen Priming Competency Not Verified: An LPN administered Humalog insulin to a resident without priming the Kwik Pen first and stated she was unaware that priming was required. The facility could not produce the nurse's skills check sheet, and the competency form reviewed did not include priming an insulin pen, despite the insulin instructions stating the pen must be primed before each injection.
A facility failed to ensure a QMA had a current license while distributing meds to residents. Record review showed the QMA was scheduled and worked on multiple days across 3 resident units, but the licensure binder and Indiana License Registry showed the QMA's license had expired. The ED stated staff should not distribute meds with an expired QMA license and that the facility had no written policy requiring QMAs to work with a current license.
Missing Mandatory Orientation and Training for Agency CNA: The facility assigned an agency CNA to provide resident care without documentation showing completion of required orientation and in-service training. The CNA stated they did not receive orientation, a training packet, or training on abuse/neglect, dementia care, behavioral health, trauma-informed care, or managing difficult behaviors before working on resident units. The ADON/Staff Educator and DON stated the required training should have been completed and documented in the employee file, but the records could not be located.
CNA Competency Review Completed After Annual Evaluation: The facility failed to ensure that a CNA received a comprehensive clinical competency skills review before the CNA's annual performance evaluation. Record review showed the CNA's annual performance review was completed before the competency review, and the DSD stated she was unaware of the requirement that the skills competency evaluation be completed prior to the annual evaluation.
Incompetent PEG Tube Medication Administration: An LPN was observed administering crushed medication via a resident’s PEG tube but poured the diluted medication directly into the tube without a syringe, causing it to spill. The LPN then did not know how to connect the syringe to the PEG tube and had to call for help, while the DON provided instruction. The resident had diagnoses including an unstageable sacral pressure ulcer, pain, and aphasia following cerebral infarction, and the DON stated the resident did not receive the full dose of medication.
A resident with urinary retention and BPH required a coude catheter, but when the catheter became obstructed, an LPN told the resident to wait until day shift for a change and did not notify the RN supervisor or seek help. Facility records showed no competency training, return demonstration, or skills validation for Foley or coude catheter care, and multiple nurses said they had not received facility-specific education or competency checks for coude catheter management.
Insulin Pen Priming Competency Not Verified
Penalty
Summary
The facility failed to ensure staff possessed the skills and competencies required when a Licensed Nurse administered Humalog insulin to R19 without priming the Kwik Pen first. On 06/02/2026 at 10:13 AM, R19 walked in the hall with a walker, then went to her room with the nurse to receive insulin. The nurse clicked up seven units in the pen and administered the insulin in R19's left arm without priming the pen, and then verified that she had not primed it and stated she was unaware she was supposed to. When the facility was asked for the nurse's skills check sheet, it could not provide it. Review of a blank medication pass competency check sheet showed no competency assessment for priming an insulin Kwik Pen. The insulin pen instructions in the pamphlet directed staff to prime the pen before each injection, and Administrative Nurse D stated she expected staff to prime the insulin pen with two units before administration. She also stated that nurses were required to complete an insulin competency check-off upon hire, and later verified that the nursing skills check lacked a competency item for priming an insulin Kwik Pen.
Expired QMA License During Medication Distribution
Penalty
Summary
The facility failed to ensure that a Qualified Medical Assistant had a current license while distributing medications to residents. A record review showed that QMA 3 was scheduled to distribute medications and had worked as a QMA on multiple days across three resident units from April through the review period. The facility's Employee Certification and Licensure binder showed that QMA 3's license had expired, and the Indiana License Registry website also indicated the license was expired. In interviews, the Executive Director stated that staff should not distribute medications with an expired QMA license and that the facility did not have a written policy requiring QMAs to work with a current license.
Missing Mandatory Orientation and Training for Agency CNA
Penalty
Summary
Certified Nurse Aide #1 was assigned resident care duties on 05/11/2026 as agency staff, but the facility could not provide documentation showing completion of required orientation and mandatory training before the aide worked independently. The missing documentation included, but was not limited to, Abuse/Neglect/Exploitation Prohibition, Behavioral Care Services/Cognitive Impairment/Dementia Training, Trauma Informed Care, Communication Training, and other required orientation and in-service training elements. During the survey, the Assistant Director of Nursing/Staff Educator stated agency staff are required to complete the same mandatory orientation and in-service training as facility staff and that training modules, sign-off documentation, and post-tests are maintained in employee files. However, the facility was unable to locate records verifying that Certified Nurse Aide #1 completed the required training. Certified Nurse Aide #1 stated they did not receive orientation, a training packet, or any of the listed training topics before being assigned to provide resident care on Units 2 and 3. The Administrator also stated that all staff are required to complete mandatory orientation and in-service training prior to working independently and that documentation should have been maintained in the employee file.
CNA Competency Review Completed After Annual Evaluation
Penalty
Summary
The facility failed to implement its policy regarding nursing staff competency by not ensuring that CNA 3 received a comprehensive clinical competency skills review before the CNA's annual performance evaluation. During a concurrent interview and record review on 5/29/2026 at 12:18 p.m., the Director of Staff Development reviewed CNA 3's personnel file, the C.N.A. Comprehensive Clinical Competency Review- Skills Checklist form, and the Annual Performance Review form. The review showed that CNA 3's clinical competency review was completed on 1/22/2026, while the annual performance evaluation was completed earlier, on 12/24/2025. During a concurrent interview and record review on 5/29/2026 at 12:26 p.m., the Director of Staff Development reviewed the facility's policy titled Nursing Staffing Competency and stated she was unaware of the facility's requirement that the annual skills competency evaluation be completed prior to a CNA's annual performance evaluation. The policy stated that the facility will identify annual skills competencies needed for each role and establish a schedule or process to facilitate completion of skills and competency evaluations, and that successfully completed orientation and skills check are required prior to the employee's annual evaluation.
Incompetent PEG Tube Medication Administration
Penalty
Summary
The facility failed to ensure licensed nurses had the necessary competency skills to administer medication via PEG tube for one resident. During an observed medication pass, an LPN prepared crushed medication for the resident’s PEG tube, donned a gown and gloves, stopped the tube feeding, and checked placement and residual. The LPN then poured water and the crushed medication into a 30 ml cup and attempted to pour the diluted medication directly into the PEG tube without using a syringe, causing the medication to spill out over and around the tube. The LPN then obtained another cup with diluted medication and a syringe but did not know how to connect the syringe to the PEG tube, hesitated, activated the call light, and stated they would call for assistance. The DON later entered the room and provided instructional assistance to the LPN on administering medication through the PEG tube. The resident had diagnoses including an unstageable sacral pressure ulcer, pain, and aphasia following cerebral infarction. A physician order directed flushing the PEG tube with 30 ml of water before and after medications and 15 ml between each medication. The LPN stated they were unsure how much medication the resident received when the diluted medication spilled during administration. The DON stated the LPN did not correctly administer the medication via the PEG tube, that the medication was spilled and the resident did not receive the full dose, and that the LPN should have notified the physician. The DON also stated the facility used skills competency checklists upon hire and yearly during a skills fair, but the LPN did not have a skills competency checklist completed upon hire and was past the 90-day timeframe for completion.
Lack of competency validation for coude catheter care
Penalty
Summary
The facility failed to ensure licensed nursing staff possessed and demonstrated the competencies needed to safely assess, manage, and provide care for residents requiring a coude catheter. Resident 9 was admitted with urinary retention and benign prostatic hyperplasia with lower urinary tract symptoms, and a care plan dated March 30, 2026, identified the need for a coude catheter. On May 7, 2026, nurse documentation and interview with the DON showed the resident’s coude catheter became obstructed during the night shift, and the LPN on duty told the resident he would need to wait until day shift staff arrived for the catheter to be changed. The DON stated the LPN reported she was not comfortable changing the coude catheter because of a lack of familiarity and experience with that type of catheter, and she did not notify the RN supervisor or seek assistance to ensure timely catheter intervention. Review of facility documentation titled Skilled Nursing Competency Training showed competencies listed for licensed practical nurses, including nephrostomy tubes and suprapubic catheters, but the facility did not include competency training, return demonstration, or skills validation for Foley catheter insertion, Foley catheter management, or coude catheter care and replacement. During interviews, four licensed nurses stated they had general catheter education in nursing school and prior experience with coude catheters at previous employers, but all reported the facility had not provided facility-specific education, training, competency evaluation, or skills validation related to coude catheter care, evaluation, insertion, replacement, or management. The DON was unable to provide documented evidence that licensed nursing staff had completed education, training, competency evaluations, or demonstrated proficiency for Foley catheter care or specialized coude catheter management.
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