Failure to Ensure Competency and Timely Response by Nursing Staff
Penalty
Summary
Nurses and nurse aides at the facility failed to demonstrate appropriate competencies in caring for residents, resulting in several deficiencies. One resident, a female with multiple complex diagnoses including metabolic encephalopathy, COPD, diabetes, morbid obesity, paraplegia, and other chronic conditions, was observed to have her call light out of reach and left on for an extended period without response. The resident reported being left in an uncomfortable position for about 30 minutes, experiencing significant back pain, and expressed dissatisfaction with a registry CNA who was unfamiliar with her care needs and did not follow her preferences. The call light panel in her room was also found to be hanging out of the wall with exposed wires, though still functional. Staff members, including CNAs, were observed not wearing ID badges, and some were unfamiliar with the residents or the facility's procedures due to infrequent assignments and lack of orientation or huddles at the start of their shifts. Another resident, also with multiple chronic conditions such as spinal stenosis, COPD, morbid obesity, and congestive heart failure, reported a negative experience with a registry CNA who took an extended break, delayed meal service, and failed to complete required showers. The resident felt unsafe during care and noted communication barriers with some registry CNAs who did not speak or understand English well enough to meet her needs. The staffer confirmed that the registry CNA was not familiar with the resident's preferences and was subsequently marked as 'do not return' based on the resident's complaints. Record reviews revealed that competency checklists for registry CNAs were incomplete or missing, with most only documenting competency in resident transfers and lacking evidence of skills in other required areas. The facility had no Director of Staff Development (DSD) to oversee training, and the infection prevention nurse, who had been covering some training duties, had not provided competency training for registry staff. The facility's policy required all nursing staff to demonstrate competency in a range of skills, but there was no evidence that this was consistently ensured for registry CNAs.