Failure to Implement and Document Required Staff Training
Penalty
Summary
The facility failed to implement and document an effective training program for both new and existing staff members. Personnel file reviews and the in-service attendance calendar revealed that newly hired staff, including an LPN and several CNAs, did not have documentation of completed training in Quality Assurance and Performance Improvement (QAPI), compliance and ethics, and infection control upon hire. Additionally, existing staff members lacked documentation of annual training in QAPI and compliance and ethics. The facility's training records only showed infection control as a topic, omitting QAPI and compliance and ethics. During staff interviews, the Director of Nursing confirmed the absence of additional education documentation in staff files and acknowledged the need to build the training program.