Incomplete Staff Competency and Certification Documentation
Penalty
Summary
The facility failed to ensure that the employee files for three of five sampled staff members, including a Licensed Vocational Nurse, a Treatment Nurse, and the Interim Director of Nursing, contained required documentation such as performance evaluations, skills competency checklists, and Basic Life Support (BLS) certifications. During interviews and record reviews with the Director of Staff Development, it was found that the Licensed Vocational Nurse's file was missing a BLS certification, skills competency checklist, and a current performance evaluation. The Interim Director of Nursing's file lacked a skills competency checklist, and the Treatment Nurse's file was missing both a skills competency checklist and a current performance evaluation. The Director of Staff Development and the Interim Director of Nursing confirmed that these documents were not present in the respective employee files and acknowledged the importance of having them to ensure staff proficiency and readiness to provide care, including resuscitative efforts. Facility policies reviewed indicated that employee job performance should be evaluated and that staff should be properly trained in CPR, but these requirements were not met for the sampled employees.