Failure to Ensure Effective Orientation and Emergency Transfer Training for Newly Hired RN
Summary
The deficiency involves the facility’s failure to provide and monitor an effective training program for a newly hired RN, specifically related to emergency procedures and hospital transfers, which contributed to a delayed response to a resident’s acute change in condition and emergent transfer. The facility’s DON and NHA stated that new nurses receive five days of training and an orientation checklist that includes emergency procedures, hospitalization, transfer forms, and emergency access for rapid transport. However, the DON acknowledged that the checklist does not have to be completed before being returned and that the orientation checklist for the involved RN had not been turned in, leaving the DON unaware of which training items had been completed. The orientation checklist for this RN was not provided to surveyors by the time of exit. The newly hired RN reported that she started at the end of the prior month and had not completed all of her training, including training on transferring a resident to an acute care hospital. On the night in question, she had to transfer two residents to the hospital for changes in condition and stated she had never done this before. She reported that another RN was assisting her with the orientation training checklist and with completing the paperwork, steps, and packet required for a hospital transfer. The assisting RN confirmed that the new RN appeared overwhelmed and unfamiliar with the transfer process and that she tried to help with the required paperwork. The new RN stated that she asked whether they should just call 911 for the resident and was told by the assisting RN to finish the paperwork while the assisting RN went to eat and would help again afterward. During this same shift, EMS and 911 records show multiple calls associated with the facility and a delay in EMS activation for the resident who was ultimately found unresponsive. 911 records documented an abandoned call from the facility, a return call from 911 during which facility staff reported no emergency, and subsequent calls from the local emergency department and ambulance service indicating that the hospital had received report on a patient from the facility but had not yet received the patient. EMS documentation for the resident later transported described dispatch for a cardiac or respiratory arrest, arrival to find the resident unconscious, minimally responsive, hypoxic, and requiring escalating oxygen support and eventual transfer to the emergency department. Hospital records documented that the resident, an older adult with dementia with psychotic features, major depressive disorder, and atrial fibrillation on Eliquis, was brought in unresponsive, hypotensive, tachycardic, cool, and cyanotic, and was intubated for airway protection. The combination of incomplete orientation, lack of verified competency in emergency transfer procedures, and the facility’s failure to ensure the new RN was effectively trained and monitored in these processes led to a delay in treatment and emergent hospital transfer for this resident. The DON confirmed that she did not know which emergency procedure and transfer-related training items the new RN had completed because the orientation checklist had not been returned. The Licensed Nurse Orientation and Skill Check form included items such as emergency procedures, hospitalization, transfer form from the electronic record, and emergency access for rapid transport, but there was no evidence these competencies had been completed or validated for the new RN. The new RN’s own statements that she had never transferred a resident to the hospital before, had not yet completed all of her training, and did not complete the first transfer’s paperwork correctly further demonstrate that the facility did not maintain an effective training and monitoring process for new nurses in critical emergency and transfer procedures, contributing to the deficient practice identified by surveyors.
Penalty
Resources
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Inadequate staff training and tracking for abuse, dementia, and behavior management. The facility did not have an effective system to ensure new and existing staff, including agency CNAs and facility nursing staff, received and completed required in-services tied to their roles. Records showed missing documentation for abuse prevention, dementia care, and behavior management training, and interviews showed staff were unclear about who was responsible for onboarding and tracking education. During an incident involving a resident with psychiatric, mood, and dementia-related needs, staff described the resident spitting and using racial slurs, while a CNA tapped the resident on the shoulder and other staff did not intervene before the abuse event.
Incomplete Annual Staff In-Service Training: The facility failed to maintain an effective staff training program requiring 12 hours of annual in-service education. Review of personnel and training records showed that five of seven staff members reviewed did not complete the required hours, with several completing only a small portion of the mandated training. The Administrator confirmed the shortfall in annual in-service training.
The facility failed to maintain an effective staff training program to ensure an RN and an LPN had documented competency to initiate IV access. Two residents had one-time IV orders, and the RN and LPN each started IV access with a 24-gauge needle, but personnel records did not show the required three witnessed IV insertion attempts required by facility policy before they performed the procedure independently.
Lack of PICC Line Training and Competency Validation: The facility failed to maintain an effective staff development program to ensure LPNs had documented education and competency for PICC line care. Two residents had PICC lines for antibiotic therapy, and agency LPNs accessed the lines to provide NS flushes and IV antibiotics. Records showed no PICC-specific training or competency validation for the LPNs, and the RA confirmed no structured PICC line training program existed for agency licensed nurses.
The facility failed to implement and complete its nurse orientation and competency validation process for new LPNs, resulting in two separate medication errors. One LPN, new to LTC and unfamiliar with the facility’s computer system, was left alone on the med cart after only partial observation-based training and without a completed competency checklist, and a resident received another resident’s medications. Another new LPN, also without documented competency sign-offs, was in joint med-pass with an untrained preceptor when a resident requesting pain medication was given sleeping pills after the preceptor pulled the wrong controlled medication and the trainee administered it. Preceptors were selected informally from floor nurses without preceptor training, and leadership interviews confirmed that required competency checklists and the facility’s own med-pass orientation policy were not consistently followed or documented.
The facility did not maintain an effective training program for new and existing staff, as confirmed by record review and interviews with the Administrator and a regional clinical leader. Available in-service records showed training only on QAPI, infection control, resident rights, and abuse, with no documented training on communication, behavioral health, compliance and ethics, or required annual nurse aide education. The Administrator acknowledged that staff had not been trained on these topics, that CNAs had not received their required annual training hours, and that there was no facility policy governing staff training. This deficiency had the potential to affect all 67 residents in the facility.
Inadequate Staff Training and Tracking for Abuse, Dementia, and Behavior Management
Penalty
Summary
The facility did not ensure an effective training program was developed, implemented, and maintained for all new and existing staff consistent with their expected roles and based on the facility assessment. The facility assessment stated the facility admitted residents with psychiatric and mood disorders needing intervention and residents with all forms of dementia, and it referenced corporate clinical support and the Nursing Staff Educator for staff in-services. However, the assessment did not include the nurse staffing agency used by the facility in the list of vendors, and it did not include a plan to ensure mandatory and ongoing in-service education and competencies were provided to agency staff. Record review showed no documented evidence that agency Certified Nurse Aides completed abuse prevention training before their hire dates, and one agency aide also had no documented evidence of dementia training or behavior management training before hire. During interview, one agency aide stated they had recently started through a staffing agency, were reassigned to provide one-to-one supervision for a resident, were unaware of the abuse incident involving that resident, and had not been oriented to the resident’s behaviors or given behavior management training before working at the facility. The aide also stated they received abuse prevention in-service only within the prior week and had submitted a post-test. The facility incident investigation documented an event in which a CNA tapped a resident on the shoulder while trying to redirect the resident, while other staff statements described the resident spitting on the aide and staff responding to the interaction. The LPN involved had only acknowledged receipt of the employee handbook and its abuse reporting policy, but there was no documented evidence of comprehensive abuse prevention, dementia management, or behavior management training before hire. Interviews with HR, the Nursing Staff Educator, the DON, and the Administrator showed inconsistent responsibility for onboarding and tracking education, no documented system for tracking agency staff training, and no ability to provide details of in-service education for staff over the prior six months.
Incomplete Annual Staff In-Service Training
Penalty
Summary
The facility failed to implement and maintain an effective training program so that each staff member received 12 hours of annual in-service training. Review of the facility assessment showed that staff were to be in-serviced annually on mandatory topics including resident abuse, neglect and exploitation, trauma informed care, and dementia management. During an interview, the Administrator confirmed that staff were required to complete 12 hours of in-service training each year. Review of personnel and training records showed that five of seven staff members reviewed did not complete the required annual training. Employee 6 completed 7.5 hours, Employee 8 completed 1 hour, Employee 9 completed 5.25 hours, Employee 11 completed 2.25 hours, and Employee 12 completed 2.0 hours of in-service education during the reviewed period. The Administrator confirmed that these employees had not completed the required annual in-service training.
Missing IV Competency Validation for Nursing Staff
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program to ensure licensed nursing staff had the knowledge and demonstrated competency to safely initiate IV access for two residents. Federal requirements and Pennsylvania nursing regulations were cited as requiring staff training and competency validation before independently performing IV therapy, and the facility policy titled Intravenous Therapy required an RN or LPN to complete three witnessed IV insertion attempts before initiating IV access. For Resident 14, a physician ordered a one-time IV for an upper respiratory infection and elevated white blood cell count, and an RN initiated IV access with a 24-gauge needle in the resident’s right forearm. For Resident 290, a physician ordered a one-time IV for hydration, and an LPN initiated IV access with a 24-gauge needle in the resident’s right forearm. Review of both employees’ personnel records did not show documentation of the required three supervised IV insertion attempts, and the Nursing Home Administrator acknowledged the facility could not provide evidence that either staff member completed the required competency validation before independently initiating IV access.
Lack of PICC Line Training and Competency Validation
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for licensed nursing staff to ensure they had the knowledge and competencies needed to safely manage PICC lines for two residents. The report states that federal requirements call for staff training based on the facility assessment, and Pennsylvania nursing regulations require nurses performing IV therapy, including PICC line care, to complete appropriate education, supervised clinical instruction, and ongoing competency validation. The facility policy on administration of medication or flush through a central venous line also stated that the procedure is complex and requires necessary education, training, and experience. One resident was admitted with a PICC line for antibiotic administration, and physician orders required routine flushing of the line with 10 mL of normal saline. The eMAR showed two agency LPNs repeatedly accessed the PICC line to administer normal saline flushes on multiple occasions in February 2026. Another resident was admitted with a PICC line for antibiotic therapy related to chronic multifocal osteomyelitis, and physician orders required the line to be flushed with 10 mL of normal saline before and after medication administration and during the day and evening shift. The March 2026 eMAR showed an agency LPN accessed the PICC line to administer flushes and IV antibiotics, including Ampicillin Sodium and Ceftriaxone Sodium. Employee personnel records showed no documented education, training, or competency validation related to PICC line management for either agency LPN. The report also states there was no evidence that the facility or contracted agency provided a structured training program, competency validation, or ongoing education specific to PICC line care for licensed nursing staff. During interview, the Regional Administrator of Clinical Operations confirmed the facility could not provide documentation of PICC line-specific training or competency validation and had not developed or implemented a training program specific to PICC line management for agency licensed nurses.
Failure to Implement Effective Nurse Orientation and Competency Validation Leading to Medication Errors
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective nurse training and competency program for new LPN staff, resulting in incomplete orientation and unverified competencies for at least two nurses. The facility maintained a New Trainee Folder and a Licensed Nurse Competency Skills Check-off form intended to cover unit safety, communication, infection control, nursing care, emergency procedures, equipment, medication administration, pain management, resident rights, abuse, dementia care, QAPI, person-centered care, cultural competency, and HIPAA. Human Resources reported that the competency checklist was to be printed and placed in a staffing binder, completed by the preceptor over the first three days, and then signed off by leadership. However, for both reviewed LPNs, these competency checklists were not completed, and there was no documented verification that they had met medication administration or other required competencies before functioning independently. One LPN, on her first day working in the facility and with no prior LTC experience, was involved in a medication error in which a resident received another resident’s medications. This LPN reported that she had only been trained by an RN from 6 AM to 10 AM on how residents took their medications and who had swallowing issues, and that she did not know how to enter orders into the computer system and was unfamiliar with the software. The RN preceptor stated that the LPN had only observed her and had not performed any tasks independently before the RN left, and that she had not checked the LPN off to administer medications alone. The Unit Manager acknowledged that the LPN had no LTC experience, that she did not complete the medication portion of the competency checklist, and that she left the LPN alone on the cart after the LPN stated she felt comfortable, despite not having seen her pass medications. The facility’s Medication Administration policy required that new personnel not administer medications until oriented to the system and that a charge nurse accompany them on medication rounds for a minimum of three days, but this process was not followed or documented for this LPN. Another new LPN, also without a completed competency checklist, was involved in a separate medication error in which a resident requesting pain medication received sleeping pills instead. This LPN reported that she was in training with a preceptor, and that both nurses were pulling medications from the same cart, with the preceptor handling controlled substances. The error occurred when the preceptor punched a sleeping pill from the wrong card, and the trainee LPN administered it, noting that the pills were both small and white and that they were trying to hurry. The LPN stated she did not recall any specific competency check-offs being done beyond a license check. The Unit Manager and ADON both confirmed that preceptors were simply floor nurses who had been at the facility longer, with no formal preceptor training, and that the current training program had only recently started. Employee files for both LPNs lacked completed Licensed Nurse Competency Skills Check-off forms as of the survey date, and leadership interviews showed uncertainty about when competency checklists should be completed and how much training the LPNs had actually received before being allowed to function independently.
Failure to Provide Required Staff Training on Communication and Behavioral Health
Penalty
Summary
The facility failed to ensure staff were trained on effective communication and other required topics, affecting all 67 residents in the building. During review of staff in-service records on 3/24/26 at 11:00 AM, the surveyor and the Administrator (V1) identified that training subjects such as communication, behavioral health, and required annual nursing aide training were missing. At 12:50 PM, the Regional Director of Clinical Services (V7) confirmed he could only locate staff training on QAPI, infection control, resident rights, and abuse, and that he was unable to find any staff training on communication, compliance and ethics, behavioral health, or any required nursing aide training. At 1:00 PM, the Administrator acknowledged that staff had not been trained on communication or behavioral health and that nurse aides had not received their required annual training hours, stating she was not aware these were required. On 4/13/26 at 3:00 PM, the Administrator further stated that the facility did not have a policy related to staff training. The facility’s daily census report dated 3/17/26 documented 67 residents residing in the facility. No additional resident-specific clinical details, medical histories, or conditions at the time of the deficiency were provided in the report.
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