F0607

L

Unverified Individual Allowed to Provide Direct Care Without Screening or Credential Verification

Slidell, Louisiana Survey Completed on 03-14-2026

Penalty

Fine: $30,565

Summary

The deficiency involves the facility’s failure to implement its written abuse, neglect, exploitation, and misappropriation prevention policy by not ensuring employment screening and verification for an individual who presented as agency staff. On the morning in question, an individual identified as S12 entered the locked building after being allowed in by a CNA and initially inquired about job openings. She was directed to the back nurses’ station to speak with LPNs. After briefly leaving to change footwear at the request of an LPN, she re-entered the facility and then represented herself to multiple LPNs as an agency CNA arriving to cover an open shift. Facility staff did not verify her identity, employment with the staffing agency, or credentials before assigning her to resident care.

S12 was handwritten onto the daily assignment sheet and assigned to provide direct care to ten residents, all of whom had significant medical conditions, including hemiplegia and hemiparesis following cerebrovascular events, COPD with acute exacerbation, gastrostomy malfunction, atrial fibrillation, non-traumatic subarachnoid hemorrhage, hypertensive urgency, acute infarction of the spinal cord, and encephalopathy. S12 reported that she rounded on residents, answered call lights, and obtained snacks from the kitchen for some residents. She specifically described answering a call light for one resident on barrier precautions, donning a gown and gloves, entering the room, rolling the resident to remove his brief, and becoming soiled with feces on her gloved hand and gown sleeve. She then requested assistance from two CNAs, removed her PPE, left the room, and did not return to complete care.

Interviews with the two CNAs confirmed that S12 had been present in the resident’s room, had begun incontinence care, and then left after removing her gloves and gown, without returning, leaving them to complete the care. Both CNAs stated they did not know whether she was facility or agency staff. The resident involved confirmed that a female aide, who did not identify herself, answered his call light, called two male CNAs to assist with changing his brief, donned a gown and gloves, became soiled, and then left the room without removing his brief or returning. Review of the visitor log and personnel list showed S12 was not listed as a visitor and was not a current employee. The benefits coordinator, DON, and administrator all confirmed that S12 was not employed by the facility or the staffing agency, that no registry or background checks or credential verification had been completed for her, and that there was no existing process to screen, orient, or complete competency evaluations for agency staff upon entry before they began resident care. This failure to verify and screen S12 before assigning her to direct resident care led to an Immediate Jeopardy situation for the residents under her care.

Additional interviews with nursing staff further demonstrated that the facility lacked an operational process to ensure agency staff were verified and oriented before working. One LPN stated that S12 was asked if she was agency staff and, upon her affirmative response, no further verification of agency employment or credentials was performed before she was placed on the assignment sheet. Another LPN acknowledged assigning S12 to care for the ten residents without confirming her agency status, screening, orientation, or competency. The DON confirmed that neither she nor other administrative staff had verified S12’s credentials or screening before S12 was allowed to provide care for approximately two hours. Staff also reported that agency personnel were generally expected to report to any hall, clock in through their agency on their phones, and check the daily assignment sheet, and that agency staff did not receive facility orientation, abuse/neglect training, or competency evaluations prior to being assigned resident care. These actions and inactions collectively demonstrate the facility’s failure to follow its own abuse prevention policy requiring screening of employees and contracted staff, resulting in an Immediate Jeopardy situation.