Deficiency in Nursing Staff Competency Documentation
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies and skill sets for specific care tasks, including enteral tube feeding, tracheostomy care, catheter care, medication administration, and dressing changes. This deficiency was identified during a review of facility documentation and staff interviews, which revealed that the facility could not provide evidence of competencies for four employees, including two registered nurses (RNs) and two licensed practical nurses (LPNs). These employees were responsible for the care of residents with various medical needs, such as enteral tube feedings, tracheostomies, indwelling catheters, and pressure ulcers. The facility had a total of 121 residents receiving medications, 10 residents with indwelling catheters, five residents with pressure ulcers, five residents with enteral tube feedings, and one resident with a tracheostomy. Despite these care requirements, the facility was unable to provide documentation confirming that Employees 4, 5, 6, and 7 had the specific competencies and skill sets necessary to meet these residents' needs. This lack of documentation was confirmed during an interview with the Director of Nursing, indicating a failure to ensure that nursing staff were adequately prepared to provide the required care.
Plan Of Correction
Cited: Employees 4, 5, 6, and 7 completed the following competencies: enteral tube feeding, tracheostomy care, catheter care, medication administration, and dressing changes. • Like: HR/designee will complete audit of current employees to ensure appropriate competencies are completed. • Education: NHA/designee will educate the staff educator to ensure plan of current staff to obtain appropriate competencies. • Audits: Staff educator/designee will audit 5 employees including new hires weekly x 4 weeks then monthly x 2 months to ensure staff have appropriate competencies completed. Results will be taken through QAPI.