Failure to Ensure Staff Competency in Emergency Kit Handling and Annual Evaluations
Penalty
Summary
The facility failed to ensure that licensed staff were competent in following facility policies and procedures regarding the handling and securing of emergency medication kits (E-Kits). During interviews and observations, two licensed staff members were unable to accurately describe the process for securing E-Kits after use. One registered nurse supervisor stated she had not received in-service training on E-Kits and could not explain the securing process, while a licensed vocational nurse provided an incorrect description of the procedure. The facility's policy requires specific steps for documenting, reporting, and securing E-Kits, which were not followed or understood by the staff involved. Additionally, the facility did not complete or document annual performance evaluations for five staff members as required by facility policy and regulatory standards. The Director of Staff Development acknowledged that these evaluations were not performed due to workload, and the Director of Nursing confirmed that the absence of evaluations meant staff competencies and areas needing improvement were not formally assessed. The facility's policy mandates yearly written evaluations to review employee performance, but this process was not carried out for the identified staff.