Failure to Provide Annual Restorative Nursing Training
Summary
The facility failed to ensure that seven employees completed the required annual Restorative Nursing Techniques education. This deficiency was identified through a review of facility policy, documents, and staff interviews. The facility's policy, dated 5/23/24, mandates that all new staff receive training during orientation and complete a checklist on both theory and skills material, which is to be repeated annually. However, training records revealed that Nurse Aides and Registered Nurses, specifically Employees E7 through E13, did not have documented training in Restorative Nursing Techniques for the specified annual periods. During an interview, the Nursing Home Administrator confirmed the lack of training for these staff members.
Plan Of Correction
All employees with upcoming evaluations will have necessary required in-service education and training, including restorative, for a total of 12 hours by their evaluation date. Employee training will be monitored, and each employee's status of education completion will be pulled at least each quarter to ensure completion in a timely manner prior to the evaluation date, by the staff development coordinator and Director of Nursing. Education to all nursing staff will be given by Staff Development or designee. QAPI on staff education training compliance will be done weekly for one month, bi-weekly for one month, and monthly thereafter. All results will be reported to the QA Committee.
Penalty
The facility did not provide required Restorative Nursing training to seven staff members, including an RN, an LPN, and several NAs, as confirmed by personnel file reviews and staff interviews. This failure was in direct violation of the facility's policy mandating annual and role-specific training for all staff.
The facility failed to provide training on restorative nursing techniques for two nurse aides, as required by facility policy. Employee E11 and Employee E15 did not receive the necessary in-service education within the specified timeframes. The Nursing Home Administrator confirmed this deficiency during an interview.
Failure to Provide Restorative Nursing Training to Staff
Penalty
Summary
The facility failed to provide required training on Restorative Nursing techniques to seven staff members, including RNs, LPNs, and NAs. According to the facility's own policy, all staff, including those under contractual arrangements and volunteers, must receive training relevant to their roles before independently providing services to residents, annually, and as necessary based on the facility assessment. Personnel file reviews for the identified staff members showed no evidence of Restorative Nursing training within the required annual period following their respective hire dates. During an interview, the Human Resources representative confirmed that none of the seven staff members received the mandated Restorative Nursing training. This lack of training was identified through a review of facility policy, staff personnel files, and direct staff interviews, establishing that the facility did not meet its own training requirements for staff competency in Restorative Nursing.
Plan Of Correction
Employee's 3, 4, 5, 6, 7, 8, and 9 will receive the Restorative Nursing training in January 2026. All employees will receive an annual Restorative Nursing training during a set month of the year. Human Resource Director will educate all Department Directors on the annual education requirements for Restorative Nursing training. Human Resource Director or designee will audit the training to assure all staff have been educated on Restorative Nursing training topic. Audit results will be turned into Quality Assurance meeting monthly.
Failure to Provide Restorative Nursing Techniques Training
Penalty
Summary
The facility failed to provide training on restorative nursing techniques for two nurse aides, Employee E11 and Employee E15. According to the facility's policy, all personnel are required to receive education and training related to resident care. However, a review of the facility's documents and training records revealed that Employee E11, hired on March 26, 2023, did not receive the required in-service education on restorative nursing techniques between March 26, 2024, and March 26, 2025. Similarly, Employee E15, hired on April 14, 2014, did not receive the necessary training between April 14, 2024, and April 14, 2025. During an interview on April 18, 2025, the Nursing Home Administrator confirmed the facility's failure to provide the required training for these two nurse aides. This deficiency was identified based on the review of facility policy, personnel in-service training records, and staff interviews.
Plan Of Correction
Immediate Intervention: All nursing staff were provided with Restorative Nursing Techniques on the electronic platform. How to identify residents who can be affected: All employees can be affected. Prevention of further occurrence: Nurse educator reviewed the training platform and discovered that 1560 was not uploaded to the training platform. Restorative Nursing Techniques has since been uploaded, and employees have been given 30 days to complete training. By June 6, 2025, all employees will have 1560 training courses completed. Corrective action required: Nurse educator to review all staff training compliance monthly and report to DON delinquent staff. DON will pursue corrective action and discipline for employees who are non-compliant. QA Program: Nurse educator will report on staff compliance of staff education monthly at QAPI.
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