Deficiency in Staff Education on Resident Rights and Facility Responsibilities
Penalty
Summary
Facility staff failed to ensure that all employees were adequately educated on resident rights and the facility's responsibilities as required by federal regulations. Record reviews showed that while the facility's assessment and policies indicated that staff training on resident rights was to occur during orientation and through quarterly in-service programs, there was insufficient documentation to confirm that this training was consistently provided. Specifically, the education and training binder only contained a list of training topics and sign-in sheets from a skills fair, without evidence of the actual content delivered or proof that all staff, including those absent from the skills fair, received the required training. Interviews with facility leadership confirmed the lack of substantiating documentation regarding the specific information provided to staff on resident rights. The Regional Director of Operation and the Administrator both acknowledged gaps in the education process, with the Administrator noting that some training was provided on an as-needed basis and that a new educator had only recently begun remote training. The absence of clear, comprehensive records and consistent training delivery led to the deficiency in staff education on resident rights and facility responsibilities.