Failure to Ensure Staff Competency in Resident Transportation
Penalty
Summary
The facility failed to ensure that nurses and nurse aides possessed the appropriate competencies to safely care for residents, specifically regarding transportation services outside the facility. Staff files lacked documentation of yearly evaluations, demonstration of skills, review of adverse events, and evidence of competency in activities within their scope of practice. One staff member's file did not include a job title, job duties, or education related to their specific role, and their yearly education consisted mainly of computer-based training without assessment of critical thinking or ability to manage care in complex environments. Interviews revealed that the facility did not provide transportation education to staff prior to the incident, and staff could not recall when such training last occurred. As a result of these deficiencies, a resident was not safely assisted during transportation services, leading to a fall in the parking lot and ejection from their motorized wheelchair. This incident resulted in the resident being transferred to the hospital. The lack of staff competency and training in transportation procedures directly contributed to the resident's injury and subsequent hospitalization.