Failure to Complete Annual Performance Evaluation for Nurse Aide
Penalty
Summary
The facility failed to ensure that annual performance evaluations for nurse aides were completed as required. Specifically, Nurse Aide 10 did not have a documented performance evaluation completed by the due date of September 24, 2024. As of January 15, 2025, there was no evidence of the evaluation being conducted. This deficiency was confirmed through a review of personnel files and an interview with the Director of Human Resources, who acknowledged the absence of the required documentation.
Plan Of Correction
1. No residents were identified with this alleged deficient practice. 2. The Human Resource Coordinator (HRC) reviewed the employee files for Certified Nurse Aides (CNA) who have been employed for at least one year to ensure performance evaluations were completed annually. Follow up completed based on findings. 3. The Executive Director (ED) reeducated the HRC and the Director of Nursing (DON) on the facility's employee job performance evaluation policy. The HRC will notify the DON of upcoming performance evaluations so that the appropriate supervisor can ensure that they are completed in a timely manner. 4. The HRC/Designee to conduct Quality Improvement (QI) monitoring of regulation deficiency of 730 to ensure nurse aide performance evaluations were completed annually based on hire date. QI monitoring conducted via nurse aide personnel file review weekly for 8 weeks. Findings to be reported to the Quality Improvement Performance Improvement (QAPI) committee meeting and updated as indicated. QI schedule modified based on findings.