F0835

L

Unverified Individual Assigned to Provide Direct Resident Care Without Screening or Orientation

Slidell, Louisiana Survey Completed on 03-14-2026

Penalty

Fine: $30,565

Summary

The deficiency involves the facility’s failure to administer an effective screening and onboarding system for non-employee staff, which allowed an unknown individual (S12) to be assigned to provide direct resident care without verification of employment, credentials, or required training. On the morning of 03/12/2026, S12 entered the locked building after inquiring about job openings and was allowed entry by a CNA (S14). She was directed to the nurses’ station to speak with LPNs identified as S10 and S13. After briefly leaving to change her footwear at the request of S10, she re-entered the building and was allowed back in by staff member S9R. Upon her return, S12 told S10, S11, and S13 that she was agency staff reporting for an open shift.

Without verifying her identity, employment with the staffing agency, or CNA credentials, S11 provided S12 with a temporary ID badge and assigned her to a group of residents (R1 through R10) on the daily assignment sheet, where her name was handwritten. These residents had significant medical conditions, including hemiplegia and hemiparesis following cerebral infarction or other cerebrovascular disease, chronic obstructive pulmonary disease with acute exacerbation, gastrostomy malfunction, unspecified 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 gown and gloves, entering the room, rolling the resident to remove a brief, and becoming soiled with feces before calling other CNAs for assistance and then leaving the room.

Interviews with administrative nursing staff confirmed that there was no process in place at the time to verify the identity of non-employees upon entry, to confirm agency assignment and credentials, or to provide facility orientation, abuse/neglect training, or competency evaluation before assigning resident care. S13, identified as part of the administrative staff, acknowledged that when S12 presented herself as agency staff, neither she nor S10 verified S12’s agency status or credentials before S11 placed S12 on the assignment sheet for residents R1–R10. S11 confirmed she did not verify that S12 was agency staff and still issued a temporary ID and resident assignment. S10 and the DON (S2) both confirmed that the facility frequently used agency staff but had no existing process to pre-screen non-employees, verify credentials, or ensure completion of orientation and abuse/neglect training prior to allowing them to provide direct care. The administrator (S1) further confirmed that there was no process to verify the identity of non-employees upon entry and that S12 was not employed by the facility or its staffing agency, yet was allowed to provide care to residents for approximately two hours before the issue was discovered.

The surveyors determined that this failure to verify and approve agency personnel prior to assignment of resident care created an Immediate Jeopardy situation beginning at 8:00 a.m. on 03/12/2026, when S12 first presented herself as agency staff and was subsequently assigned to provide direct care to residents R1 through R10. The facility’s ineffective administrative system for screening and onboarding agency personnel resulted in residents being placed at a likelihood of serious harm, injury, impairment, or death, as stated in the report. The visitor log for that day did not list S12, further evidencing the lack of a functioning entry and verification process for non-employees.