Widespread Failure to Complete and Document Required Staff Training
Penalty
Summary
The facility failed to provide, implement, and maintain an effective training program for new and existing staff as required by its own In-Service Training policy. The policy, revised in April 2021, required all staff to participate in initial orientation and annual in-service training on topics including effective communication, resident rights, abuse prevention and reporting, QAPI, infection prevention, behavioral health, and compliance and ethics. Record review showed that 75 of 83 staff did not receive the required annual abuse identification, prevention, and reporting training; 39 of 83 staff did not complete dementia management training; 31 of 83 staff did not complete resident rights training; 30 of 83 staff did not complete QAPI training; 49 of 49 direct care staff did not complete effective communication training; 20 of 83 staff did not complete infection control training; 16 of 83 staff did not complete compliance and ethics training; and 13 of 49 direct care staff did not complete behavioral health training. Further review of training records revealed missing or incomplete documentation for several required topics. For dementia training, 39 staff lacked documentation of completion and no alternative in-service records were provided. For resident rights, the facility produced an in-service training document but no sign-in sheet to verify attendance. For QAPI, an in-service document and sign-in sheet were provided, but 30 staff still lacked evidence of completion. No direct care staff had documented completion of effective communication training, and although a copy of the training content existed, there was no proof it had been used. Infection prevention records showed some staff completed online and in-service training, but 20 staff still lacked required training. Compliance and ethics training records listed all staff on an online roster, but many had no completion dates and no documentation of use was provided. Behavioral health training records showed 13 staff without required online training and no in-service documentation. In interviews, the NHA reported that most training was done during onboarding, stated that about 91% of trainings were completed, and claimed all abuse and dementia trainings were finished, but she could not produce records to support these statements, and acknowledged that some training sessions such as lunch-and-learns were not documented. The regional nurse consultant stated the current training plan was not effective to ensure all staff were sufficiently trained as required.
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