Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to ensure that annual performance evaluations were completed for three out of nine nurse aides reviewed, specifically Employees E11, E12, and E13. According to the facility's policy, revised in September 2020, a performance evaluation should be conducted at the end of an employee's 90-day probationary period and at least annually thereafter. However, during a review of the facility's documentation, it was found that the facility could not provide completed performance evaluations for Employees E11 and E12 when requested on February 5, 2025. Additionally, on February 7, 2025, the facility was unable to provide a completed performance evaluation for Employee E13. This deficiency was identified based on the facility's failure to adhere to its own policy and regulatory requirements for regular in-service education and performance reviews.
Plan Of Correction
Employee E11, E12 and E13 evaluations were completed. All nurse aide employee files reviewed for annual evaluations and completed if necessary. Administrator/designee re-educated HR director on Performance Evaluation policy. HR director/designee will audit random nurse aide employee files monthly x3 to ensure that 90 day probationary eval (if needed) and yearly evaluation is completed and report findings to QAPI committee monthly.