Failure to Complete Staff Background Checks Leads to Resident Distress
Penalty
Summary
The facility failed to ensure a safe environment free from actual and potential abuse by not performing required background check screenings on current employees who had direct contact with residents. This lapse affected all 79 residents in the facility, as several staff members, including kitchen, housekeeping, maintenance, and nursing staff, were found to have worked without completed background checks or healthcare worker registry verifications. The administrator acknowledged that background checks were not completed for multiple employees, some of whom had direct access to residents, and that the issue stemmed from a lapse in service by the background check provider due to nonpayment, which was not followed up on by facility leadership. One resident, who has diagnoses of Bipolar Disorder, Depression, and Anxiety, reported experiencing verbal abuse from a kitchen staff member. The resident stated that the staff member used inappropriate language, which caused the resident to feel fear, anger, embarrassment, and reluctance to leave their room while the staff member was employed. The incident was reported and investigated, but the facility was unable to substantiate the allegation due to lack of corroborating evidence and the possibility of a misunderstanding in a noisy environment. However, the resident maintained that the incident occurred and described significant emotional distress as a result. Interviews and record reviews revealed that the facility's policies required background checks and registry verifications to be completed prior to employment, but these procedures were not followed. The administrator admitted responsibility for ensuring these checks were completed and confirmed that several staff members had worked without the required screenings. The medical director emphasized the importance of timely background checks to protect vulnerable residents, and the facility's own policies outlined a zero-tolerance approach to abuse, neglect, and misappropriation of property, which was not upheld in practice.
Removal Plan
- Administrator was in-serviced by the VP of clinical services on background checks and the need to run prior to staff member working.
- Administrator will in-service department heads on ensuring that staff will not work without background check being completed.
- All staff members that are currently on the working schedule have had a background check completed and are eligible to work in a skilled facility.
- Initial audit completed for all current employees, that a background check has been completed.
- Review of current policy and procedure to reflect current practices.
- No staff will work before having a background check.
- A quality assurance tool was implemented: Audit will be completed for new hires to ensure that background check was completed prior to first working day. Administrator and department manager.
- Root Cause Analysis Completed for background checks.