Deficiency in Staff Training Documentation and Implementation
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for all new and existing staff, including those providing services under contract and volunteers, as required. Specifically, two employees, an LVN and an RN, did not have documentation of annual dementia and restraint reduction training in their files. The LVN's file showed dementia training shortly after hire but lacked evidence of restraint reduction training, aside from a signed policy. The RN's file included an ungraded dementia test and no documentation of restraint training. Interviews with both staff members revealed uncertainty about when or if they had received the required training, with one stating that in-person training was cancelled and that training is now conducted online, often verbally, with signatures at the end. The RN did not recall any training on dealing with behaviors or restraints. The interim administrator confirmed that staff are responsible for completing their own online training and acknowledged recent changes in the training program, which made tracking employee progress more difficult. The facility was also without an HR person at the time, and the administrator was unable to provide a training policy during the survey. These actions and inactions led to the deficiency in staff training documentation and compliance.