Failure to Complete Registry Checks and Report Adverse Event
Penalty
Summary
The facility failed to complete nurse aide registry checks prior to staff having possible or probable contact with residents for three of six sampled staff members. Specifically, a nurse aide and a business office manager both began working before their registry checks were completed, with the checks occurring 10 and 12 days after their respective start dates. Additionally, a housekeeper worked multiple days without any evidence of a completed registry check. The facility administrator confirmed that these staff members worked prior to the completion of the required registry checks. The facility also failed to report an adverse event involving a resident who was admitted with spinal stenosis. The resident experienced a fall during a transfer from a wheelchair to a bed using a full body lift, when the sling strap broke, causing the resident to fall partially onto the bed and partially onto the floor. The incident resulted in soreness and bruising, and was attributed to malfunctioning equipment. The director of nursing confirmed that this event was an unusual, unanticipated event with the potential to cause serious injury, and acknowledged that it was not reported to the appropriate agencies as required by facility policy.