Failure to Provide Required In-Service Dementia Training for CNAs
Penalty
Summary
The facility failed to ensure that nurse aides received the required in-service training, specifically dementia management training, as mandated by federal regulations. A review of employee records for two certified nursing assistants (CNAs) revealed that one CNA had not received dementia management training since 2022, and the other since 2024. Additionally, one CNA reported never receiving dementia management training from the facility, only from her school. The Director of Staff Development (DSD) confirmed there was no tracking system in place to ensure CNAs completed at least 12 hours of in-service education per year, nor was there an updated in-service calendar or timely updates to employee files. The DSD acknowledged the lack of upcoming dementia management training and was unable to provide documentation of recent training for CNAs and other staff. The facility's policy and procedure for the DSD role outlined responsibilities for planning, developing, and coordinating the nursing assistant training program, including maintaining appropriate records and ensuring compliance with federal and state guidelines. However, these duties were not fulfilled, resulting in the deficiency related to insufficient in-service training for nurse aides.
Plan Of Correction
Plan /Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken. DSD rounded on 6/12/25 and found no other resident affected by the deficient practice. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur: Starting 6/12/25, DSD will maintain a calendar of what in-services will be given every month to include Dementia Management. DSD initiated a log on 6/19/2025. Continue Education to oversee CNAs have enough CEUs that include Dementia Management with Competency to ensure residents are properly cared for. DSD on 06/17/25 and 06/19/25 conducted required in-service training with CNAs and Licensed Nurses with emphasis given on Dementia Management that all Nurse Aides to be in-serviced quarterly and for at least 2 hours. Dementia-specific Training as part of facility orientation program. Administrator conducted 1:1 in-service training with the DSD on Dementia on 6/19/2025. Performance Monitoring: Starting 7/01/25, the DON will review the DSD's training calendar to ensure inclusion of Dementia Training and the DON will report in the monthly QAPI meeting for discussion and review. Monthly discussion and review will occur for 3 months. Facility Plan to Monitor Corrective action(s); and Sustain Compliance: DSD will report any deficient practices, review Performance, and report to Administrator and report to QAPI monthly meetings for compliance.