Deficiency in Compliance and Ethics Program
Summary
The facility failed to maintain an effective compliance and ethics program, as evidenced by an incident involving a registered nurse (RN) and a licensed practical nurse (LPN). On two occasions, the facility's narcotic documentation forms were missing signatures, indicating a lack of proper verification of controlled substance counts. On May 28, 2024, RN-D instructed LPN-E to sign a narcotic documentation form for a count he did not witness. This action was stopped by a surveyor, highlighting a breach in protocol. The facility's policy requires two nurses or medication aides to verify and sign off on narcotic counts at each shift change, which was not adhered to in this instance. Further investigation revealed that RN-D lacked documentation of ethics training upon hire, despite a facility policy requiring such training. Additionally, the facility did not have an active ethics committee, and the director of nursing (DON) was unaware of any regular meetings or the existence of such a committee. The facility's policies emphasize accurate documentation and ethical conduct, yet these were not followed, leading to the deficiency noted by the surveyors.
Penalty
Resources
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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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