Failure to Ensure Compliance and Ethics Program Adherence by DON
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) adhered to ethical expectations and professional standards, as evidenced by backdating evaluations with incorrect documentation. There was no evidence that the DON had received education or competency training for the role, nor was there documentation of the DON's signed job description or acknowledgement of Compliance and Ethics Program orientation education. The Human Resource Assistant, who also served as the Compliance Officer, stated that compliance program information was provided during employee orientation, but did not participate in clinical or resident care meetings and only became involved in employee-related situations such as investigations or terminations. Additionally, compliance program posters, which should have been readily visible for employees, were only present on the Assisted Living Facility side of the building and not on the Skilled Nursing side. The Nursing Home Administrator confirmed that the required compliance documentation for the former DON was missing from the employee file. The facility's own standards outlined the need for sufficient resources, ongoing communication, and annual training to promote quality care, but these requirements were not met as described in the findings.