F0607

F

Failure to Implement Screening Procedures Allowed Agency CNA to Work Under False Identity

Edgerton, Wisconsin Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement its written policies and procedures for screening staff, specifically agency CNAs, before they worked with residents. The facility had policies titled “Compliance with Reporting Allegations of Abuse/Neglect/Exploitation” and “Abuse, Neglect and Exploitation,” which required screening of potential employees, contracted temporary staff, students, volunteers, and consultants for histories of abuse, neglect, exploitation, or misappropriation of resident property. These policies also required background, reference, and credential checks, and documentation that such screenings occurred. However, the policies had no documented implementation, revision, or review dates, and the facility relied on the staffing agency’s processes without independently verifying the identity of agency staff upon arrival for orientation or their first shift.

The events leading to the deficiency began when an agency CNA, later identified as CNA S, worked 12 shifts at the facility while posing as another CNA, identified as CNA T. The staffing agency had provided the facility with background and credential information for the person identified as CNA T, including a photocopy of an out-of-state driver’s license, and all credentials for that identity were verified and valid. The facility’s Nursing Home Administrator (NHA) stated that the agency obtained all required background information and uploaded it to a shared portal, and that the facility did not ask agency staff to provide identification at orientation because they had no reason to suspect the person was not who they claimed to be. The contract between the facility and the staffing agency specified that the agency would verify credentials, including photo identification, criminal background checks, and license verification, but also stated that this did not relieve the facility of its own statutory, regulatory, or contractual obligations to independently verify credentials and information.

On one evening, local police investigated a fraudulent food order that had been delivered to the facility and identified the payer as the agency CNA known at the facility as CNA T. When police returned to the facility the next day to arrest this individual, they compared the woman presenting as CNA T with the photocopied driver’s license on file and noted that the woman did not match the photo. Further questioning revealed that the woman was actually CNA S, who admitted she was a travel CNA who had previously worked for the staffing agency but was suspended for attendance issues. She stated she created an account for her mother, CNA T, and had been working under her mother’s identity. During this period, she had worked multiple AM, PM, and NOC shifts on different floors under the false identity. The facility did not report this incident as a suspicion of a crime to the state survey agency, and the NHA acknowledged that no changes had been made to the process for verifying the identity of new agency personnel after the false-identity issue was discovered.

During the surveyor’s review of facility records, it was also noted that a resident filed a grievance alleging that on one date a CNA left her wet and did not check and change her according to her plan of care. The facility’s investigation determined that the staff member involved was new, and the grievance was filed against the CNA identified as CNA T. Documentation of education provided to this CNA described her as new to the CNA occupation and a phenomenal worker who answered call lights and did not complain about tasks. This grievance occurred during the time period when the individual working under the name of CNA T was actually CNA S. The surveyor concluded that, due to the facility’s failure to implement its abuse/neglect and misappropriation policies and to confirm the proper identity of an agency CNA prior to work, an individual was able to work under a false identity for multiple shifts without proper screening by either the staffing agency or the facility, and that the facility did not change its screening practices even after learning of the false identity.