Failure to Conduct Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete a performance evaluation of each nurse aide at least once every 12 months, as required by §483.35(d)(7). This deficiency was identified during a review of employee personnel records and staff interviews. Specifically, two nurse aides, hired on May 29, 2013, and October 27, 1998, respectively, did not have documented evidence of annual performance evaluations. An interview with a human resources employee confirmed that these evaluations were not completed for the two nurse aides in question. This issue was previously cited on January 26, 2024, indicating a recurring problem with compliance in this area.
Plan Of Correction
The performance reviews for employees 8 and 9 were completed. All employees eligible for an annual performance review received one. Education was provided to the facility DON to ensure the completion of annual performance reviews. The Administrator or designee will conduct weekly audits for 12 weeks to ensure that eligible employees receive a performance review. The results of the audits will be reviewed at the facility's QAPI meeting for recommendations.