Incomplete Staff Education and Competency Documentation
Penalty
Summary
The facility did not have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services necessary to assure resident safety and to help residents attain or maintain their highest practicable well-being, as determined by resident assessments and individual care plans. Observations, record reviews, and interviews revealed that documentation of completed annual mandatory education for nursing staff was incomplete and varied among staff members. The facility assessment identified required staff training and competencies, including resident rights, abuse prevention, infection control, dementia care, and other specialized care needs, but education records for several nurses and nurse aides were found to be incomplete. Interviews with staff indicated there was no effective system in place to notify staff of required education, and staff reported a lack of time to complete mandatory training. Education materials were left near the time clock for staff to complete on their own, but there was no consistent auditing or tracking of completion. The Director of Nursing, who also served as the Nurse Educator, acknowledged that education organization and tracking were lacking, and that annual evaluations had not been completed. The facility had recently undergone changes in leadership, and previous education records were missing, requiring the creation of a new tracking system. Staff also reported that there was no specific education provided for care of residents with dementia versus those with mental illness.