Failure to Complete and Retain Staff Background Checks
Penalty
Summary
The facility failed to complete and retain documentation of background reports for five out of six sampled staff members, including registered nurses, licensed vocational nurses, a treatment nurse, and a certified nursing assistant. During interviews and record reviews, it was found that several employee files lacked background check documentation, with some background checks either missing, incomplete, or conducted years after the staff member's hire date. In some cases, background reports were still processing or had not been printed and reviewed once completed. The Director of Staff Development (DSD) confirmed that background checks should have been completed upon hire and that missing documentation was partly attributed to a change in facility ownership, during which some records were misplaced. The Director of Nursing (DON) stated that it was the responsibility of the Human Resources Department or the DSD to ensure background checks were completed for newly hired nurses. Both the DSD and DON acknowledged that background checks were necessary to confirm staff eligibility to provide care and to ensure resident safety. The facility's policy and procedure required background checks and verification of employment eligibility status to be conducted in accordance with established policies, but these procedures were not consistently followed, resulting in incomplete or missing background check documentation for multiple staff members.