Failure to Evaluate and Document Staff Competencies
Penalty
Summary
The facility failed to develop and implement a system to evaluate staff competencies in skills and techniques necessary to provide individualized care for residents. Review of personnel files for three sampled staff members—a nursing assistant, a registered nurse (agency staff), and an LPN—showed no documentation of training or competency evaluations. The facility assessment indicated that staff competencies were to be reviewed annually and tracked via a computerized system, but records for these staff were missing. Agency staff reported not receiving training, orientation, or skills evaluations, and were only given a brief tour of the building. Interviews with facility leadership and staff revealed a lack of awareness and process for ensuring agency staff had adequate training and competencies, with the administrator and staffing coordinator acknowledging that these steps had not been completed or documented. Resident Council feedback indicated concerns about agency staff not providing adequate care, with reports of staff congregating at the nurses' station and residents experiencing long call light wait times. The facility utilized temporary contracted staff as needed, but there was no evidence that these staff received the required training or competency assessments. The absence of documentation and lack of a clear process for evaluating both permanent and agency staff placed residents at risk of receiving care from inadequately trained or under-qualified personnel.