Deficiency in CNA Dementia Care Training Documentation
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) received the required hours of training and annual in-services on dementia care management, as mandated by regulations. Specifically, the facility could not provide documentation that three CNAs had completed the necessary training. CNA #23, hired in July 2023, had a last recorded training in November 2024, which did not include dementia care management. CNA #24, hired in March 2019, had their most recent training documented in November 2024, also lacking evidence of dementia care management education. CNA #25, hired in May 2023, had no documentation confirming completion of the required dementia care management education. During an interview, the Assistant Director of Nursing acknowledged the absence of documentation for these CNAs.
Plan Of Correction
Plan of Correction: Approved April 23, 2025 Corrective Actions for Residents Identified Required in-service training for Nurse Aides must include dementia management training and resident abuse prevention training. Certified Nurse Aides #23, #24, and #25 did not have the required hours of the mandatory training in regards to Dementia training. No residents suffered ill effects. Upon notification of this deficiency, Certified Nurses Aides #23, #24, and #25 were all contacted and provided with Dementia in-service and all now meet the standard for the 12 hours of annual in-service. Audits of the employees assigned residents and units revealed no ill effects to those or any other resident as a result of this deficiency. Residents at Risk: Any resident can be affected by this deficient practice. In-service coordinator/educator conducted an audit of all CNAs to determine if any other CNA was out of compliance with Dementia education or the annual 12 hour education, and none were noted out of compliance. The facility respectfully states that while all staff and therefore residents could have been affected, no other staff or resident was affected. Systemic Changes: All CNAs will receive mandatory training on an annual basis by Nurse Staff Educator/Designee. The Administrator has reviewed the facility’s policy on Employees Annual Mandatory Education and found it to be in compliance with all local, state and federal regulations. Monitoring of Corrective Actions: Audits will be presented at QAPI meetings monthly by the DNS to determine continued need. Review of Nursing staff attendance and completion of education will be monitored by Infection Preventionist/Nurse Staff Educator/ADON/DNS/Designee. The DNS/Designee will be responsible for completion of this plan of correction. Audits will be completed in regards to Dementia training/Annual Mandatory for certified aides biweekly x 4 then monthly x 3 months. Audits to be completed by Human Resource Director/Nurse Staff Educator/Designee. Audits will be presented at QAPI meetings monthly by the Human Resource Director/DNS to determine continued need. The DNS/Designee will be responsible for completion of this plan of correction. The Administrator has created an audit tool to monitor compliance with CNA annual mandatory education including Dementia education. Responsible: The DNS/Designee will be responsible for completion of this plan of correction. Completion Date: 5/31/2025