F0726

E

Lack of Documented Nurse Competencies and Structured Orientation

Battle Creek, Michigan Survey Completed on 03-06-2026

Penalty

No penalty information released

Summary

The facility failed to ensure that licensed nurses had documented knowledge, competencies, and skill sets to provide care that maximizes each resident’s well-being. Review of five randomly selected nurse personnel files (three RNs and two LPNs) showed no evidence of education, training, or competency assessments at hire or annually. The Human Resources Director stated that any annual competencies or education should be in the employee file and confirmed that none of the five nurses had formal competencies completed during the new hire process or yearly, and that there were no required online or hands-on training programs in place at the time.

Staff interviews further demonstrated the lack of a functioning competency program. A long-term RN reported working in the building for 22 years and stated that monthly educational in-services had stopped about two years prior and that he did not recall any formal yearly competency evaluations. Another RN described his new hire orientation as meeting with HR, reviewing policies/handbook, and about 1.5 days of job shadowing with a unit manager, with no hands-on training, formal education, or skill competency/checklist that he could recall. The DON reported that, to her knowledge, there had been no annual competencies in place and that prior new hire orientation consisted only of verbal information from HR and informal floor orientation, despite a written facility policy requiring structured orientation, assignment of a preceptor, documented competency evaluation forms, and maintenance of these forms in personnel files.