Lack of Training for Agency Staff Leads to Improper Resident Handling
Penalty
Summary
The facility failed to ensure that staff were competent and trained in providing care to a resident with behavioral health issues. Specifically, a Certified Nurse Aide (CNA) from an agency was not trained to manage the behaviors of a resident who exhibited physical and verbal aggression, rejection of care, and wandering. The CNA was observed holding the resident's arms and preventing them from leaving their room, despite the resident's request to do so. This action was contrary to the facility's policy, which emphasizes behavior prevention and intervention training for staff, although agency staff were not included in this training. The resident involved was cognitively intact and had a history of being abusive to caregivers, with poor impulse control and threatening behaviors. The care plan for the resident included interventions such as observing for signs of agitation, redirecting the resident, and consulting psychiatry or psychology as needed. However, on the day of the incident, the CNA was seen physically pushing the resident back into their room and holding their arms, actions that were not aligned with the care plan or facility policy. Interviews with facility staff revealed that the CNA had not received any training in behavior management or the facility's specific Mandt training, which is designed to teach de-escalation tactics. The facility's policy excluded agency staff from this training, and there was no documentation to ensure that agency staff were aware of the facility's behavior code or how to react to residents with behavioral issues. The facility's leadership acknowledged that agency staff were not provided with the necessary training due to time and resource constraints, which contributed to the deficiency in care provided to the resident.
Plan Of Correction
Plan of Correction: Approved March 5, 2025 1. No agency workers will be placed on 1:1 assignments with patients. The policy for 1:1 assignments was reviewed and updated to reflect that agency staff will not be assigned to 1:1 cares. 2. All residents who require a 1:1 assignment have the potential to be affected by this deficient practice. The Director of Nursing will audit all patients with a 1:1 order to ensure that no agency workers are assigned to their care. 3. The Director of Nursing or designee will educate all staff, including nursing/administrative staff, responsible for scheduling 1:1 assignments, not to place agency staff on these assignments. 4. The Director of Nursing or designee will audit schedules daily for 3 months and quarterly thereafter to ensure that no agency staff are placed on 1:1 assignments. Findings will be reported to QAPI for further guidance. 5. The Director of Nursing will be responsible for compliance.