Uncertified Staff Member Performed Resident Care Duties
Summary
A deficiency was identified when a staff member assigned as a "Monitor" was found performing resident care activities, specifically Activities of Daily Living (ADLs), for a resident. The staff member, referred to as Monitor #1, did not possess a Certified Nurse Aide (CNA) license, as confirmed by a review of her personnel file and her own admission during an interview. Monitor #1 stated that she had attended CNA school and had taken the certification test but failed. Despite this, she reported performing tasks such as changing and caring for residents, which are duties reserved for certified and competent nurse aides. Further investigation revealed that facility leadership, including the Director of Nursing and other administrative staff, were not aware that Monitor #1 was providing direct resident care. The facility's job description for the "Monitor" position did not include providing resident care, but rather focused on supervision, assistance with transportation, and support during mealtimes and leisure activities. The facility was unable to provide an assignment sheet for the relevant date, and interviews confirmed that the Monitor was not authorized to perform CNA responsibilities. The resident involved had a history of cognitive impairment and required significant assistance with daily activities.
Plan Of Correction
F728 Hiring/Use of Nurse Aides 1. Corrective Action - On 4/10/25, monitor #1 received an education and disciplinary action for failure to adhere to their job description. - On [R], monitor #1 was terminated and is no longer employed at the facility. - On 4/10/25, HR Director audited all nursing assistant files to assure they are within their 120 days based on regulatory requirement. All nursing assistants (total of 11) met regulatory criteria for employment as nursing assistants. - On 4/10/25, HR Director audited all nursing assistants to ensure compliance with job description and scope of practice. - On 4/10/25, HR Director educated all monitors (9) on their job description. - On 4/10/25, HR Director audited all monitors' employee files for signed job description and not providing direct care to residents. 2. Identification of other residents or areas having the potential to be affected due to the nature of the deficiency: - All residents have the potential to be affected by this deficient practice. 3. Measures Put Into Place: - HR Director and/or designee will audit monthly X6 months all nursing assistants to ensure that they do not work more than 120 days. - Director of Nursing/designee will audit the monitors' performance to assure it is compliant with their job description weekly X4 weeks and then monthly X6 months. 4. How Will These Actions Be Measured: - The results of the weekly and monthly audits will be submitted to the Quality Assurance and Process Improvement Committee Meeting monthly for 6 months. - Based on the results of these audits, a decision will be made regarding the need for continued submission and reporting. - The next Quality Assurance and Process Improvement Committee Meeting will be held on June 6, 2025.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A facility failed to ensure a NA completed or enrolled in a state-approved training and competency evaluation program within four months of hire. Record review showed the NA had not obtained CNA certification or enrolled in a CNA program, and the HR Manager confirmed the NA had not completed the required training and should not have been working after the allowed timeframe.
A full-time nurse aide was allowed to continue working after failing to obtain CNA certification within the required timeframe. Records showed the aide completed facility training and skills check-off, but staffing schedules placed him as the only aide on multiple halls with one RN while interviews confirmed he had not passed the clinical exam and was still providing resident care. The ADON said he was kept on to help him get certified, while the DON and interim ADMN acknowledged he should not have remained in the aide role after the certification deadline.
Facility staff failed to ensure three NAs completed the required training program within the 120-day timeframe. Personnel records showed the NAs had been hired months earlier but lacked documentation of successful completion and registry verification. The Administrator and DON said the aides were moved to another department for 30 days and then returned to the floor as NAs, believing the clock restarted, and later stated personal scheduling issues contributed to the delay.
A CNA was scheduled for resident care independently even though the facility could not produce the required competency/training checklist or proof of completed 12.0 contact hours. HR, the scheduler, the training/in-service nurse, the DON, and the Administrator all confirmed the checklist was missing from both the prior and current employment files, despite the CNA being taken off orientation and placed on the CNA schedule.
Nurse aide training and competency requirements were not met when a nurse aide worked more than four months without documentation of completing the CNA training program. The facility stated it could not secure a CNA instructor in time, so the aide was briefly terminated and rehired part-time while enrolled in an online CNA class, with the DON and ADON monitoring module and test completion.
A facility failed to ensure an agency staff member who was a full-time employee completed the required nurse aide training and competency evaluation program within 4 months of hire. Record review showed no start date, license number, or expiration date for the aide, and the Administrator confirmed the aide was not certified, had only on-the-job caregiver training, and should not have worked in the LTC program.
Nursing Assistant Training and Competency Deficiency
Penalty
Summary
The facility failed to ensure that nursing assistants had completed or were enrolled in a state-approved training and competency evaluation program within four months of hire. Record review showed that NA #1 was hired on 12/15/26 and had not obtained CNA certification and had not enrolled in a CNA program within four months of hire. During interview on 6/26/26 at 12:16 PM, the HR Manager confirmed that NA #1 had not completed the state-approved training and competency evaluation program and stated that NA #1 last worked on 4/30/26, confirming that NA #1 should not have been working after 4/15/26.
Nurse aide worked beyond certification timeframe
Penalty
Summary
The facility failed to ensure that a full-time nurse aide was certified within four months of hire. Record review showed the nurse aide was hired on 12/03/2025 as a nurse aide in training and had applied for a CNA position on 11/19/2025. The employee file included a pre-employment checklist indicating CNA certification verification was marked yes, but the checklist was not signed or dated by a staff member approving the aide to start employment. Training records showed the nurse aide completed a skills check-off on 12/22/2025 and received a NATCEP certificate dated 12/22/2025 for completing the nurse aide training program at the facility. However, staffing schedules showed the aide continued to work as the only nurse aide on halls with one nurse on multiple shifts from 04/23/2026 through 06/23/2026, including assignments on Hall C, Hall B, Hall A, and Hall D. The census report dated 06/23/2026 showed 24 residents on Hall B and 20 residents on Hall C. During interviews, the nurse aide stated he passed the written exam but did not pass the clinical exam on the first attempt and did not pass a later clinical attempt in April 2026. He stated the facility told him he should have been let go in April 2026 when he did not get certification, but that it was overlooked because of a change in ownership. The CNA stated he normally worked the 2 p.m. to 10 p.m. shift and was allowed to provide resident care with other staff present. The ADON stated the aide was allowed to continue working after failing the clinical test because the facility was trying to help him get certified, and the DON stated she expected nurse aides who could not obtain certification by 120 days after hire to be demoted to hospitality aides. The interim ADMN stated the aide should have been termed if unable to get certified within 4 months and stated the aide was termed on 06/24/2026 when the issue was discovered.
Nurse Aides Worked Beyond Training Timeframe Without Required Completion
Penalty
Summary
Facility staff failed to ensure three nurse aides, NA A, NA B, and NA C, completed the required nurse aide training program within four months of employment. The facility’s policy stated nurse aides may work no greater than four months without documented successful completion of the training and competency evaluation program and verification through the state nurse aide registry. Review of personnel files showed NA B and NA C were hired on 12/17/25 and NA A was hired on 01/02/26, but none of the files contained documentation that the required nurse aide training program had been completed. During interviews, the Administrator and DON stated there were four nurse aides in classes and three were beyond their 120-day window. They reported the aides were moved to a different department for 30 days and then returned to work as nurse aides. The Administrator later stated he/she did not realize the timeframe did not restart when the aides were moved to another department, and the DON said he/she believed the 120 days started over if the aides worked in another department such as laundry for at least 30 days. The DON stated the aides would be removed from the floor and not allowed to work until their test was complete. In a later interview, the Administrator said NA A did not complete training in time because he/she was in nursing school, and NA B and NA C had childcare issues that affected their ability to complete classes while still getting a paycheck.
Missing CNA Competency Verification Before Independent Assignment
Penalty
Summary
The facility failed to ensure adequate competency and verification of skills for one CNA, CNA TB, and failed to complete the facility-required competency/training checklist before taking her off the training schedule for resident care. CNA TB’s employee record showed an original hire date of 8/25/25, a termination date of 11/11/25, and a rehire date of 1/26/26. During the state recertification survey from 6/1/26 to 6/3/26, she was verified as currently employed, but the HR Director and HR staff stated there was no record of the facility completing 12.0 continuing education because she was treated as a new hire after restarting in January 2026. The Staffing Scheduler confirmed CNA TB was on the CNA schedule and had been removed from the training/orientation schedule to provide resident care independently, but did not know when her training would be completed and stated she would not be on the floor if she had not signed off on competencies. The scheduler also said she assumed the competency checklist had been completed because CNA TB had been released from orientation, while the training/in-service nurse denied knowledge of the missing checklist and the DON and Administrator confirmed the competency checklist was not found in either the prior employment file or the current rehire HR file. The facility policy required completion and maintenance of the general and department orientation checklists to verify competency and understanding before removal from the training schedule.
Nurse aide worked beyond 4 months without completed CNA training
Penalty
Summary
The facility failed to ensure nurse aides were not used for more than four months without completing the required training and competency evaluation. Review of the facility policy showed nurse aides must complete a state-approved training program and that the facility would not employ any individual as a nurse aide for more than four months unless the individual was competent and had completed the required training and competency evaluation program or had otherwise been deemed competent under the applicable requirements. Review of NA A’s personnel file showed a hire date of 01/12/26, but there was no documentation that the nurse aide training program had been completed. The facility’s online CNA class schedule and sign-in sheet showed NA A started classes on 04/27/26. During interviews, NA A, the Administrator, the DON, and the ADON stated the facility did not have a CNA instructor available in time for NA A to complete the classes, clinical training, and certification within the required four months. The Administrator said NA A was terminated for about one week and then rehired on a part-time basis while completing the online class, and the DON and ADON said the ADON monitored completion of online modules and knowledge tests while the aides worked toward certification.
Uncertified Nurse Aide Worked Without Required Competency Evaluation
Penalty
Summary
The facility failed to ensure that agency staff 10, identified as a full-time employee, completed the required nurse aide training and competency evaluation program or a State-approved competency evaluation program within four months of hire. During record review, the facility document titled "Agency Staff Checklist for Credentials" showed no specific start date for NA10, and the certification information did not include a license number or expiration date, indicating the individual was not certified. In interview, the Administrator confirmed that AS10 did not meet competency evaluation requirements or have nurse aide certification, stated that AS10 received on-the-job training for caregiver duties but would not be appropriate for the facility's LTC program, and acknowledged that AS10 should not have worked in the LTC facility. The facility's CNA job description also stated that staff must have current CPR and Hawaii CNA certification.
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