Deficiency in Annual In-Service Education for Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff received the required annual in-service education, as evidenced by the review of personnel records for three nursing staff members: RN Employee E16, LPN Employee E25, and RN Employee E26. The facility's policy on training requirements, last reviewed on December 9, 2024, mandates the development and maintenance of an effective training program for all staff, covering essential topics such as infection control, resident rights, and safety procedures. However, the personnel records for these employees did not include documentation of annual in-services on critical subjects like infection prevention, fire safety, disaster preparedness, resident abuse, and other key areas. During an interview, Human Resources Employee E5 confirmed the facility's failure to provide the necessary annual in-service education for the identified nursing staff. This deficiency indicates a lapse in the facility's compliance with regulatory requirements to ensure that nursing staff possess the competencies and skills necessary to meet residents' needs, as outlined in their individual care plans. The lack of documented training raises concerns about the facility's ability to maintain a safe and effective care environment for its residents.
Plan Of Correction
1. Employees Registered Nurse (RN) Employee E16, Licensed Practical Nurse (LPN) Employee E25, and Registered Nurse (RN) Employee E26 will receive mandatory education including infection prevention and control, fire prevention and safety, disaster preparedness, resident abuse, resident confidential information, Quality assurance, resident psychosocial needs, restorative nursing techniques, resident rights, cultural competency, and communication. 2. HR Director/designee to audit employee files to determine the mandatory education including infection prevention and control, fire prevention and safety, disaster preparedness, resident abuse, resident confidential information, Quality assurance, resident psychosocial needs, restorative nursing techniques, resident rights, cultural competency, and communication that needs to be completed by each employee. 3. Future mandatory education will be completed by employees annually. HRD/designee will audit employee files to ensure the annual mandatory education is completed monthly x12 months. Those employees not completing the education will be removed from the schedule. 4. Results to be submitted to QAPI for review and approval.