Emergency Preparedness Training Deficiency
Summary
The facility failed to ensure that 18 out of 63 staff members received annual training in emergency preparedness policies and procedures. This deficiency was identified during a recertification survey through record review and interviews. There was no documented evidence to confirm that these staff members had completed the required training in the emergency plan. During an interview, a registered nurse acknowledged the oversight and mentioned consulting with the Organizational Development Coordinator to address the training gap. This deficiency could potentially affect all residents in the facility.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 1. There were eighteen (18) staff identified as not having completed annual Emergency Preparedness Education. B. Any staff member who was identified as incomplete will complete the annual Emergency Preparedness Training prior to 3/04/2025. Any staff who did not complete the Emergency Preparedness Training by 03/04/2025 will be removed from the schedule and unable to work on Skilled Nursing Unit until verification of completion. 2. All residents of the Skilled Nursing Facility have the potential to be affected by this alleged deficient practice. B. All other staff working in the Skilled Nursing Facility will be reviewed for required completion and those who have not, will receive the training. 3. The Organizational Development Coordinator will run completion reports. An Educational report for completion status of the Emergency Preparedness Training will be reviewed monthly to ensure all staff are compliant with Emergency Preparedness Training. 4. Completion report of the Emergency Preparedness Training will be reviewed at the monthly Quality Assurance Performance Improvement Committee for recommendations. Responsible Party - Director of Nursing / Designee
Penalty
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