Inadequate Training for Agency Staff Leads to Resident Restraint
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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Provide Behavioral Health Training: Behavioral Health training was not provided for two NAs as required by facility policy and the facility assessment. Personnel records did not show the required annual training for either NA, and HR confirmed the missing training during interview.
Missing Required Alzheimer’s and Dementia Training for DON and NA-C: The facility failed to ensure the DON and an NA-C completed required initial or annual Alzheimer’s/dementia training. Record review showed both staff lacked training on Alzheimer’s disease and related disorders, ADL assistance, problem solving with challenging behaviors, and communication skills. The administrator acknowledged the missing training, while facility orientation materials and the facility assessment identified dementia care topics as part of staff training.
The facility failed to ensure an agency CNA had completed required behavioral health training. Record review showed no documentation of the training, and Administrative Staff B stated the facility expected the agency to provide required training and in-services before scheduling staff. The facility also could not provide a policy related to required staff in-services.
Behavioral Health training was not provided to five of five direct care staff reviewed, including an LPN, three NAs, and an RN. The NHA stated that education is tracked by calendar year and that no 2025 education records could be found for these employees, and the HR Director confirmed the training was not provided.
Failure to Provide Required Behavioral Health Training: The facility did not provide evidence that 5 CNAs who had worked there for more than 1 year received required behavioral health training. Review of records and staff interviews showed the facility had no organized system for tracking annual training, no Staff Development Coordinator or Nurse Educator, and training records were kept in boxes from the previous DON.
The facility did not ensure that all CNAs, including agency CNAs, received required behavioral health training as outlined in its facility assessment, which called for dementia management, resident abuse prevention, and care of cognitively impaired residents with behaviors. Review of training records for two agency CNAs showed no behavioral health training over the prior year, and both CNAs reported they had not received such training from either the facility or their agency, despite one CNA confirming they provide care to all residents. The AIT and DON acknowledged that these CNAs had not received the required behavioral health training.
Failure to Provide Behavioral Health Training
Penalty
Summary
Behavioral Health training was not provided for two of three staff members, Nurse Aide Employee E2 and Nurse Aide Employee E3, as required by facility policy and the facility assessment. Review of the facility's Continuing Education policy indicated that compliance with the facility's standards, policies, and procedures is a condition of employment, including compliance with the training program. Review of the Training Requirements-Behavioral Health Training policy indicated that the facility will provide Behavioral Health training. Employee E2's personnel record showed a hire date of 3/12/24, but the current file did not show Behavioral Health training for the period 3/12/25 through 3/12/26. Employee E3's personnel record showed a hire date of 4/5/24, but the current file did not show Behavioral Health training for the period 4/5/25 through 4/5/26. During an interview, Human Resource Employee E9 confirmed that the facility failed to provide Behavioral Health training for these two staff members.
Missing Required Alzheimer’s and Dementia Training for DON and NA-C
Penalty
Summary
The facility failed to ensure that 2 of 8 sampled staff members, the DON and NA-C, had initial or annual Alzheimer's and dementia training. Review of the Employee Roster and job/hire date documents showed the NA-C had a hire date of 2/23/26 and the DON had a hire date of 5/28/24. Review of their Alzheimer's Disease or Related Disorder Training records showed both staff members had not completed training covering an explanation of Alzheimer's disease and related disorders, assistance with activities of daily living, problem solving with challenging behaviors, or communication skills. During an interview on 5/19/26 at 4:25 p.m., the administrator stated that the 2 of the 8 staff had not completed their Alzheimer's training as required and expected the training to be completed initially and annually. The facility's undated New Hire Requirements for Relias orientation education listed dementia care topics, including understanding dementia, communication, actions and reactions, Alzheimer's/dementia versus normal aging, ADL assistance, challenging behaviors, and caregiver stress management. The 5/12/26 Facility Assessment identified staffing would be adequate for caring for residents with mental health conditions, history of trauma, and dementia, and the facility's training program for new and existing staff included dementia management, abuse prevention, effective communication, special needs of residents, and caring for residents who are cognitively impaired. A policy on the facility's Alzheimer's dementia training program for new hires and annual training was requested but not provided.
Failure to Verify Required Behavioral Health Training for Agency CNA
Penalty
Summary
The facility failed to ensure agency staff received the required behavioral health training consistent with the facility assessment. During record review on 05/14/26, the facility was unable to provide documentation that agency CNA P had completed behavioral health training. During an interview the same day, Administrative Staff B stated she was responsible for scheduling agency staff and that the facility expected the agency to have provided the required training and in-services to its staff before they were scheduled at the facility. The facility was also unable to provide a policy related to required staff in-services when requested.
Failure to Provide Behavioral Health Training to Direct Care Staff
Penalty
Summary
Behavioral Health training was not provided to five of five direct care facility staff reviewed, including an LPN, three NAs, and an RN. During interviews, the NHA stated that staff education is tracked by calendar year from January through December and that the State Agency requested education records for these employees. The NHA later stated that the facility was unable to find any education records for the employees for the year 2025. The HR Director also confirmed that the facility failed to provide Behavioral Health training to the five direct care staff members reviewed.
Failure to Provide Required Behavioral Health Training
Penalty
Summary
The facility did not ensure that required behavioral health training was provided to 5 of 5 direct care staff reviewed. The surveyor reviewed the annual performance reviews and training records for CNA TT, CNA UU, CNA VV, CNA WW, and CNA XX, all of whom had worked at the facility for more than 1 year. The facility was unable to provide evidence that any of these CNAs had received the required behavioral health training. The facility policy titled Training Requirements states that training content includes behavioral health and that training is based on a facility assessment. During interviews, the HR Director stated that HR handled new employee onboarding but did not track annual training, and stated there was no Nurse Educator or Staff Development Coordinator. The NHA and Director of Operations confirmed there was no evidence that behavioral health training had been provided and stated that training records were in boxes kept by the previous DON, with no organized system for employee training documentation.
Lack of Behavioral Health Training for Agency CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nurse Aides (CNAs), including agency CNAs, received behavioral health training as required by the facility’s own Facility Assessment Tool. The Facility Assessment Tool dated 3/26/26 specifies that required in‑service training for nurse aides must include dementia management, resident abuse prevention, and, for nurse aides providing services to individuals with cognitive impairments, training on the care of cognitively impaired residents with behaviors. Review of the Facility Daily Census Report dated 4/29/26 shows that 72 residents were residing in the facility at the time of the survey. Review of the employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of behavioral health training. In interviews, one agency CNA (V9) stated that they had not received behavioral health training from either the facility or the hiring agency, and another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) confirmed that these agency CNAs had not received behavioral health training from the facility or their agency.
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