Failure to Ensure Nursing Staff Competency and Required Training
Penalty
Summary
The facility failed to ensure that nursing staff, including both licensed nurses and nurse aides, were properly trained and demonstrated the necessary competencies to provide care as outlined in the Facility Assessment. Specifically, the facility did not ensure that licensed nursing staff were trained and competent in identifying, assessing, evaluating, intervening, and responding to changes in wound conditions, nor did they implement treatment recommendations for several residents. For one resident, this failure resulted in the deterioration of a pressure wound from stage 2 to unstageable over a three-month period due to the lack of implementation of wound consultant recommendations. A review of seven clinical nursing staff personnel files revealed that the facility did not conduct or document required training and competency evaluations upon hire or annually, as specified in the Facility Assessment. The missing competencies included essential areas such as activities of daily living (ADLs), fall prevention, change in condition, skin integrity, infection control, dementia care, and medication administration. There was no evidence that staff had completed or demonstrated competency in these areas, nor that such training was provided as required. Interviews with facility leadership, including the DON, Administrator, Medical Director, and President of Clinical Operations, confirmed that the expected training and competency checks had not been completed. The DON acknowledged that no training or competency assessments had been conducted with clinical staff, and the Administrator noted the absence of key staff responsible for education and training, resulting in uncertainty about the current training system. Leadership agreed that the required education and competencies were not maintained as per facility policy and regulatory requirements.