Inadequate Training for Agency Staff Leads to Resident Restraint
Penalty
Summary
The facility failed to include all staff, particularly agency staff, in their behavioral health care training program, which led to an incident involving a resident with behavioral issues. The facility's policy required training for all employees, including full-time, part-time, and per-diem staff, but explicitly excluded agency staff from this requirement. This lack of training was evident when an agency Certified Nurse Aide (CNA) was not equipped to handle a resident's behaviors appropriately. The CNA restrained the resident by holding their arms and preventing them from leaving their room, which was against the facility's behavioral management protocols. The resident involved had a history of physical and verbal behaviors, rejection of care, and wandering, as documented in their care plan. The care plan included interventions such as observing for signs of agitation, redirecting the resident, and consulting psychiatry or psychology as needed. However, the agency CNA was not trained in these interventions or the facility's specific behavioral crisis intervention training, known as Mandt training. This training was provided to regular staff but not to agency staff, as confirmed by interviews with the facility's staff educator and nursing leadership. The incident was reported when other CNAs heard the resident yelling for help and observed the agency CNA physically restraining the resident. Despite being instructed to release the resident, the CNA initially did not comply. Interviews with facility staff revealed that agency staff were not given the same training as regular employees due to time and resource constraints. The Director of Nursing and the Administrator acknowledged that agency staff were not included in the Mandt training, which is crucial for managing residents with behavioral issues. This oversight in training contributed to the inappropriate handling of the resident by the agency CNA.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 1. Certified Nursing Assistant # 1 was immediately terminated on 01/12/2025. 2. All behavioral residents have the potential to be affected by this deficient act. The Director of Nursing will audit all agency staff who provide cares to behavioral patients to ensure that agency staff are trained in the appropriate response when behaviors occur. Agency staff will be educated on the definition of code Rainbow responses. The agency education policy was revised to include proper response in the event of a behavior. 3. The Director of Nursing or designee will educate all current and future agency staff on appropriate responses when behaviors occur and during code rainbows. 4. The Director of Nursing or designee will audit all current and future agency workers weekly times 3 months and quarterly thereafter to ensure that they receive appropriate training in proper responses when behaviors occur during code Rainbows. The audit is going to ensure that all agency staff is trained. Findings will be reported to QAPI for further guidance. 5. The Director of Nursing is responsible for this plan of correction. *A code Rainbow is code for a behavior: This alerts the special response team to respond to behaviors.