Failure to Ensure Nursing Staff Competency and Completion of Required Dementia Training
Penalty
Summary
The facility failed to ensure that nursing staff, specifically a Certified Nursing Assistant (CNA), had the appropriate skill sets and completed required annual trainings, as mandated by facility policy and federal regulations. The facility's policy required all staff to receive training on dementia care upon hire, annually, and as needed, with the Staff Development Coordinator responsible for maintaining training records. However, review of training records revealed that one CNA had not completed 60 out of 62 required trainings over a 13-month period, including essential topics such as dementia care, challenging behaviors, and mental health in LTC. The facility assessment indicated that dementia and cognitive impairment were prevalent among residents, with 19 residents diagnosed with dementia in the previous two quarters, and all staff were expected to be trained in these areas. An incident occurred in which a resident with dementia began yelling in the hallway. The CNA in question, who had not completed the required dementia care training, responded by pulling the resident's gown up to cover his mouth and then spraying an aroma therapy mist toward the resident's face, which also affected another CNA present. This action caused the resident to become more agitated. The CNA later admitted to being stressed by the resident's behaviors and confirmed she did not recall receiving any dementia care training from the facility. The other CNA present reported that the actions taken by the untrained CNA escalated the resident's distress. Interviews with facility leadership, including the Staff Development Coordinator, Human Resources Director, and Nursing Home Administrator, confirmed that staff completion of required trainings had not been monitored until recently. Staff were only able to complete computer-based trainings while in the facility, and there were reported difficulties accessing available computers. The facility had no documentation of the CNA attending any in-person dementia care training during her employment, aside from initial orientation. This lack of training and oversight resulted in the potential for delivery of care that did not support the resident's highest practicable well-being.
Plan Of Correction
Resident #103 no longer resides at the facility. CNA S no longer works at the facility. Facility residents have the potential to be affected. The DON/Designee conducted an audit to identify CNAs who have not completed Dementia training on 7/2/25. The Staff Development Coordinator/Designee will educate licensed nurses and certified nursing aides on education and training requirements and Tips for Managing Agitation, Aggression, and Sundowning on or before 7/14/25. Staff will not be allowed to work until education is completed. CNA s will be required to have completed at least 2 dementia-related training courses within the past 12 months prior to 7/14/25. The DON/Designee will conduct weekly audits of CNA education assignments to ensure that education is being completed. The audit will be conducted one time per week for eight weeks or until substantial compliance is achieved. Results of the audits will be submitted to the QAPI committee for its review and recommendations. The Director of Nursing is responsible for ongoing compliance.