Failure to Complete Required Staff Competency Evaluations
Penalty
Summary
The facility failed to conduct required staff competency evaluations for two of three sampled certified nursing assistants (CNAs), as mandated by its own policies and procedures. Specifically, one CNA did not have a performance skills checklist in their employee file, and another CNA, who was hired several months prior, did not have a documented performance evaluation. The Director of Staff Development (DSD) acknowledged that she was new to the system and was unaware of when the skills checklist for one CNA was performed, and also confirmed that the performance evaluation for the other CNA had not been completed. The DSD stated that performance evaluations are generally performed ninety days after hire and then annually, but these were missing for the two CNAs in question. The Director of Nursing (DON) confirmed that an audit of employee files had been conducted, and without the required performance evaluations and skills checklists, the facility would not be able to determine if staff lacked knowledge or required additional training. The facility's policies require that job performance be reviewed at the end of a 90-day probationary period and at least annually thereafter, and that competency requirements and training for nursing staff are established and monitored by nursing leadership. The absence of these evaluations and documentation for the two CNAs represents a failure to ensure that staff have the appropriate competencies to care for residents as required by facility policy.