Failure to Complete Annual Nurse Aide Performance Reviews
Penalty
Summary
The facility failed to complete annual performance reviews for five nurse aides, as required by federal regulations. Personnel records for these nurse aides, with hire dates ranging from 2019 to 2023, were reviewed and showed no evidence that a performance review had been conducted at least once every 12 months for any of them. This deficiency was identified through documentation review and confirmed during interviews with the Nursing Home Administrator and the Director of Nursing. The lack of documented performance reviews means that the facility did not assess the job performance of these nurse aides on an annual basis. Additionally, there was no indication that in-service education was provided based on the outcomes of such reviews, as required. The findings were based solely on the absence of required documentation and confirmation from facility leadership.
Plan Of Correction
Performance reviews were completed on E4, E5, E6, E7, E8. Current nurse aide files were reviewed, and follow-up was completed as needed. Education will be completed by the Administrator/designee with supervisors and the interdisciplinary team to ensure performance reviews are completed based on the employees' hire date. The DON/designee will review nurse aide performance reviews to ensure they are completed based on their hire date, with weekly reviews for 4 weeks then monthly for 2 months. The results of the audits will be reviewed by the Quality Assessment and Assurance Committee for the need to complete further audits.