Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
Surveyors determined that the facility failed to complete annual performance evaluations for three nurse aides, as required by federal and state regulations. Personnel record reviews showed that for three employees, there was no documented evidence of a performance evaluation being completed at least once every 12 months. The specific employees had hire dates ranging from 1991 to 2017, and their last recorded evaluations did not meet the annual requirement. During an interview, the Nursing Home Administrator confirmed that annual performance evaluations were not completed for the three nurse aides in question. This deficiency was identified through a review of employee records and direct confirmation from facility leadership, with no evidence provided to show compliance with the required evaluation schedule.
Plan Of Correction
No evidence of any actual ill effect exists on any residence in our community due to the lack of adherence to the requirements of completion of performance evaluations for staff members identified as #7, 8, and 9. Performance evaluations were completed on these staff members to ensure they meet such requirements. Performance evaluations are being conducted/completed on the current CNA staff. Information on a deficiency basis on these evaluations will be utilized for future training purposes. In addition, performance evaluations will be scheduled with staff on their original anniversary date. Management staff have been educated about the need for annual performance evaluations, and a system of tracking and scheduling is created to ensure human resources send out monthly reminders of those required. A tracking tool will be reviewed monthly for six months to ensure performance evaluations are completed and filed in the individual staff records. Findings will be presented to the Quality Assurance Performance Improvement committee for recommendations, an explanation of any identified variance infractions.