Personnel Record Deficiency for RN Employee
Penalty
Summary
The facility failed to ensure that personnel records for Registered Nurse (RN) Employee E2 included essential documentation such as a job description, educational background, employment history, and a reference check. This deficiency was identified during a review of the facility's policy, employee personnel records, and staff interviews. The facility's policy, "Safety-01 Abuse, Neglect, Exploitation general policy," mandates that reasonable efforts be made to obtain personal and professional reference information before an employee's first day of employment, with documentation of these attempts. However, RN Employee E2, who was hired on 9/3/24 and began working independently by 9/17/24, did not have the required documentation in her personnel file. The Nursing Home Administrator confirmed this oversight during an interview.
Plan Of Correction
The personnel record for registered nurse (E-2) has been updated to include the employee's job description, educational background, employment history and a reference check. Human Resources and the In-service director have been re-educated on the importance of ensuring that all pre-employment documentation including but not limited to the employee's job description, educational background, employment history and a reference check must be obtained prior to the first day of employment. All new hire paperwork including the employee's job description, educational background, employment history and a reference check will be audited every two weeks for two months by the administrator or designee to ensure all documentation is completed prior to their first day of employment. Any deficient practice will be immediately corrected. All data will be forwarded to the QAPI committee and the need for additional monitoring will be determined by the committee.