Deficiency in Nursing Staff Competency Documentation
Penalty
Summary
The facility was found to be deficient in ensuring that licensed nursing staff had the necessary competencies and skills to provide adequate care to residents. This deficiency was identified during a survey conducted on January 10, 2024, when the surveyor requested evidence of skills competency evaluations for licensed nurses. The requested competencies were related to medication administration, dementia and behavioral care, catheter and tracheostomy care, wound care, and abuse prevention and reporting. During an interview with the facility's educator, identified as Employee E12, it was revealed that the facility was unable to provide the requested documentation of skills competencies for the nurses. Employee E12 admitted that the facility did not have the necessary records to demonstrate that the nursing staff had been evaluated for the required competencies. This lack of documentation indicates a failure to ensure that the nursing staff possessed the specific skills needed to meet the residents' care needs as outlined in their individual care plans.
Plan Of Correction
Staff Educator conducted competency assessments for licensed nurses. Licensed Nurses who currently work in the facility now have skills competency evaluations for: Medication Administration, Dementia and Behaviors, Urinary Catheters, Tracheostomy care, wound Care and Abuse prevention and reporting. Staff Educator or Designee will conduct Skills competency evaluations for all licensed nurses at least annually. Staff Educator or Designee will conduct Skills competency evaluation audits Quarterly. Results will be kept on file and reported on Monthly QAPI.