Failure to Re-Educate All Nurse Aides After Substantiated Neglect
Penalty
Summary
The facility failed to implement its policy regarding the re-education of all nurse aide (NA) staff following substantiated allegations of neglect involving a resident with dementia, blindness, limited functional mobility, and generalized muscle weakness. In two separate incidents, nurse aides did not follow the resident's care plan, which required two-person assistance and the use of a full body Hoyer lift for transfers. In both cases, the aides involved did not use the lift, resulting in a skin tear in one incident and pain in the resident's leg in another. Although the facility's policy required that all NAs be re-educated after such incidents, documentation showed that only the directly involved aides received re-education. There was no evidence that the rest of the NA staff received the required training. The administrator confirmed that not all NAs were re-educated as stipulated by the facility's policy.