Failure to Complete Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to complete required annual performance reviews for all five reviewed CNAs, creating a deficiency in monitoring and evaluating staff performance. Personnel record review showed that one CNA hired in November 2021, one CNA hired in February 2023, one CNA hired in July 2023, one CNA hired in November 2023, and one CNA hired in January 2024 each had no documented performance review completed at least every 12 months. The Business Office Manager stated there were no evaluations for any of these five staff members and acknowledged that evaluations were supposed to be done annually. The DON also acknowledged that annual performance reviews had not been completed. The facility did not provide a policy regarding performance reviews prior to exit. This deficient practice resulted in the potential for inadequate care and unmet care needs for all 44 residents residing in the facility. All 44 residents in the facility were identified as being potentially affected by the lack of annual performance reviews for the CNAs, but no specific resident medical histories or conditions at the time of the deficiency were described in the report.
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