F0940

E

Failure to Ensure Required Annual Staff Training for Night-Shift LVN

El Paso, Texas Survey Completed on 12-04-2025

Penalty

No penalty information released

Summary

The facility failed to develop, implement, and maintain an effective training program for all new and existing staff, as evidenced by missing required annual trainings for one of six staff reviewed, an LVN working night shift. Review of this LVN’s personnel record showed that annual training did not include evidence of training consistent with their expected role, specifically in the areas of compliance and ethics, abuse, neglect and exploitation, and restraint reduction. Record review further showed that the LVN’s last annual trainings in these topics were completed in September 2018, with no subsequent documentation of completion.

In interviews, HR staff confirmed that all staff, including nurses and CNAs, were required to complete annual trainings and that this LVN’s required trainings had not been completed since 2018. HR stated that staff usually complete annual trainings together at one time and referred to the LVN’s direct supervisor for why this was not done. The DON stated that the LVN was a night shift nurse and that trainings for night shift nurses were left for them to read and sign, and that she was responsible for ensuring nursing staff completed annual trainings by reviewing who had signed. The Administrator stated he was responsible for ensuring staff were up to date with annual trainings, acknowledged that all staff were required to complete them regardless of shift, and noted that night shift nurses were harder to reach. He stated that staff not being up to date on trainings such as restraint reduction and abuse and neglect could lead to staff not knowing how to properly proceed in events involving restraint or identifying abuse and neglect. The facility’s Staff Development Program policy required all personnel to participate in initial orientation and regularly scheduled in-service training classes.