Lack of Staff Competency Evaluation and Training in Key Care Areas
Penalty
Summary
The facility failed to develop and implement a system to evaluate and document staff competencies in essential care areas, including diabetes management, medication administration, PTSD, Substance Use Disorders (SUD), Gradual Dose Reductions (GDR), trauma informed care, fall management, and incident root cause analysis. Review of personnel files for eight sampled staff members, including LPNs, RNs, and Nursing Assistants, revealed no evidence of training or competency assessments in these areas. Staff interviews confirmed that they had not received adequate training or competency evaluations related to these topics. The facility assessment indicated that the resident population included individuals with diabetes, histories of SUD, trauma/PTSD, anxiety, cognitive impairment, and other mental health conditions, requiring specialized and individualized care. Further interviews with facility leadership, including the Resident Care Manager, Director of Nursing, and Clinical Resource Nurse, confirmed the absence of documentation for staff training in PTSD, SUD, GDR, or trauma informed care. The computerized training system and skills fairs used by the facility did not provide evidence of staff competency in these critical areas. The Administrator acknowledged the expectation that staff should have adequate training and competencies to meet the needs of the resident population, but the records did not support that this was occurring.