Failure to Complete Annual Staff Evaluations, Competencies, and Trainings
Penalty
Summary
The facility failed to ensure that nurses, nurse aides, and housekeeping staff had completed required annual performance evaluations, skills competencies, and trainings. Interviews with staff members revealed that several could not recall the last time they completed annual evaluations, skills competencies, or specific trainings such as sexual harassment, abuse prevention, fire safety, or CPR. Record reviews confirmed that employee files were missing documentation of current licenses, annual evaluations, skills competencies, training records, vaccination records, and background checks for multiple staff members, including both nursing and housekeeping personnel. The Director of Staff Development and the Administrator acknowledged that all employee files should be kept up to date and maintained on site, but files for both facility-employed and contracted staff were incomplete or missing required documentation. The facility's own policy indicated that performance evaluations should be conducted annually or as needed, but this was not consistently followed. The lack of up-to-date employee files and missing documentation for required trainings and competencies affected all reviewed staff, including nurses, CNAs, and housekeeping staff. This deficiency was identified through interviews, record reviews, and policy review, with staff and leadership confirming the importance of maintaining current records to ensure staff competency and compliance with facility requirements.