Deficiency in Emergency Preparedness Training Documentation
Summary
The facility failed to maintain an appropriate Emergency Preparedness Plan training program for its staff, as evidenced by the lack of documented annual training for two staff members. The facility's Emergency Preparedness Plan requires staff to receive training at orientation and an annual in-service on emergency preparedness policies and procedures. However, the training records for an LPN showed that the last documented training was completed in July 2023, with no records for 2024. Additionally, the training records for the Kitchen General Manager indicated training was completed in 2024, but the specific day was not documented, and there were no records for 2023. During interviews, the Administrator acknowledged the absence of documentation for the LPN's 2024 training, attributing it to the LPN being on leave when the training occurred. The Administrator also expressed uncertainty about the Kitchen General Manager's training, as they were contracted through another company, but noted that they should have received orientation training upon starting in 2023. The Administrator admitted that a second attempt to complete the LPN's training should have been made upon their return to work.
Plan Of Correction
Plan of Correction: Approved May 5, 2025 Licensed Practical Nurse #13 was provided Emergency Preparedness Training. Kitchen General Manager was provided Emergency Management Training. All Facility Staff were assigned Emergency Management Training to complete with exam at end to ensure competence. All Department Managers received education on Emergency Preparedness Training and ensuring their employees complete them on an annual basis. Human Resources assigns Emergency Management training upon hire, and employees will not start work until training is completed. The training software automatically assigns the training on an annual basis to all employees. The Director of Nursing or designee will monitor the training record monthly to ensure all staff have completed the emergency management training. Audits will be reviewed Quarterly with the Quality Assurance and Performance Improvement Committee for 1 year to ensure compliance. Person Responsible for Completion: Director of Nursing
Penalty
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