Failure to Maintain Effective Staff Training on Resident Safety and Medication Management
Penalty
Summary
The facility failed to maintain an effective training program for both facility and agency staff, resulting in multiple deficiencies related to resident safety and medication management. In one incident, a resident with severe cognitive impairment and a history of elopement risk was able to exit the facility unsupervised. Staff did not respond to door and Wanderguard alarms in a timely manner, and agency staff were unfamiliar with the alarm systems and elopement protocols. Interviews revealed that staff were unsure of procedures during the incident, and agency nurses had not received adequate orientation or training on facility-specific safety protocols, including the use of alarms and elopement response. In separate incidents involving the administration of controlled substances, discrepancies were found in the documentation and handling of narcotic medications for two residents. There were inconsistencies between the medication administration records (MAR) and proof of use sheets, with doses recorded on one document but not the other. Agency nurses were not properly educated on the facility's narcotic handling procedures, and shift-to-shift narcotic counts were not always completed or documented correctly. Some agency staff signed narcotic count sheets with only the word "agency" instead of their names, and there were missing counts on certain days. Interviews with staff and review of orientation materials revealed that agency nurses did not consistently receive or complete required training on critical facility policies, including those related to elopement and controlled substances. The orientation checklist for agency personnel did not include post-tests or detailed information on door alarms, Wanderguard systems, door codes, or controlled substance administration. As a result, both new and existing staff, including agency personnel, were inadequately prepared to ensure resident safety and proper medication management.