Failure to Implement Effective Nurse Orientation and Competency Validation Leading to Medication Errors
Summary
The deficiency involves the facility’s failure to implement an effective nurse training and competency program for new LPN staff, resulting in incomplete orientation and unverified competencies for at least two nurses. The facility maintained a New Trainee Folder and a Licensed Nurse Competency Skills Check-off form intended to cover unit safety, communication, infection control, nursing care, emergency procedures, equipment, medication administration, pain management, resident rights, abuse, dementia care, QAPI, person-centered care, cultural competency, and HIPAA. Human Resources reported that the competency checklist was to be printed and placed in a staffing binder, completed by the preceptor over the first three days, and then signed off by leadership. However, for both reviewed LPNs, these competency checklists were not completed, and there was no documented verification that they had met medication administration or other required competencies before functioning independently. One LPN, on her first day working in the facility and with no prior LTC experience, was involved in a medication error in which a resident received another resident’s medications. This LPN reported that she had only been trained by an RN from 6 AM to 10 AM on how residents took their medications and who had swallowing issues, and that she did not know how to enter orders into the computer system and was unfamiliar with the software. The RN preceptor stated that the LPN had only observed her and had not performed any tasks independently before the RN left, and that she had not checked the LPN off to administer medications alone. The Unit Manager acknowledged that the LPN had no LTC experience, that she did not complete the medication portion of the competency checklist, and that she left the LPN alone on the cart after the LPN stated she felt comfortable, despite not having seen her pass medications. The facility’s Medication Administration policy required that new personnel not administer medications until oriented to the system and that a charge nurse accompany them on medication rounds for a minimum of three days, but this process was not followed or documented for this LPN. Another new LPN, also without a completed competency checklist, was involved in a separate medication error in which a resident requesting pain medication received sleeping pills instead. This LPN reported that she was in training with a preceptor, and that both nurses were pulling medications from the same cart, with the preceptor handling controlled substances. The error occurred when the preceptor punched a sleeping pill from the wrong card, and the trainee LPN administered it, noting that the pills were both small and white and that they were trying to hurry. The LPN stated she did not recall any specific competency check-offs being done beyond a license check. The Unit Manager and ADON both confirmed that preceptors were simply floor nurses who had been at the facility longer, with no formal preceptor training, and that the current training program had only recently started. Employee files for both LPNs lacked completed Licensed Nurse Competency Skills Check-off forms as of the survey date, and leadership interviews showed uncertainty about when competency checklists should be completed and how much training the LPNs had actually received before being allowed to function independently.
Penalty
Resources
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The facility failed to maintain documentation showing that an SSA received required orientation, competency validation, and job-specific training. Review of the SSA’s file showed no training records after hire, and the DSD and ADMN confirmed that only verbal training had been provided and that no formal training plan was in place. The SSA stated he had very limited knowledge of his job duties and responsibilities.
Failure to maintain an effective staff training program was cited when the facility could not provide documented proof that a CNA completed required CEUs for certification renewal. CNA 3 said the hours were completed, but the DON could not verify several 2024 training records because signatures, attendance, topics, or proper documentation were missing, and the DSD stated the facility had no specific policy for maintaining in-service training records.
An LPN involved in a missing narcotics incident returned from suspension and worked a shift without documented education on drug diversion and narcotics reconciliation. The incident involved an Oxycodone IR 5 mg pack that appeared tampered with, with Loratadine tablets substituted for Oxycodone and five tablets missing. The DON and Staff Development/Educator acknowledged the education should have been completed before the LPN resumed work.
Missing Mandated Reporter Training Documentation: The facility failed to ensure an LVN completed Elder Abuse Mandated Reporter training and kept proof of that training in the personnel file. The DSD/LVN could not find any abuse training record in the file or electronic system, and the DON stated that without documentation there is no way to verify the training was completed. The facility policy required abuse, neglect, and exploitation training for new staff.
Missing EBP Competency Training for CNA and LVN: The facility failed to document EBP competency training for two staff members, a CNA and an LVN. Record review and interviews showed the IPN and DSD could not provide evidence that either staff member completed the required annual competency assessment or EBP training, and the facility policies required infection control competency and EBP training upon hire and at least annually.
The facility failed to document emergency preparedness training for a dietary server, a PTA, and a speech therapist. Records reviewed by surveyors did not show the required training for these staff members, and interviews with the DON and HRD confirmed gaps in the transcripts and uncertainty about completion for some employees. The facility policy stated that new and existing staff, volunteers, and contractors were to receive required training on key topics, including resident rights, abuse, dementia management, and infection control.
Missing Training Documentation for SSA
Penalty
Summary
The facility failed to develop, maintain, and implement an effective training program for an existing Social Services Designee/Assistant (SSA) because it was unable to provide documentation verifying that the SSA had completed the required competency validation or job-specific training. During concurrent interview and record review, the SSA’s employee file was reviewed and showed that the SSA was hired on 6/16/26, but there was no documentation of competency validation or job-specific training in the file. The Director of Staff Development stated that all staff were expected to receive appropriate orientation and training before performing job duties and that documentation of training and competency validation should be maintained in the personnel file. The DSD confirmed that the facility could not provide documentation of the SSA’s competency or job-specific training and stated she would attempt to locate the records by contacting the Administrator, who was the SSA’s direct supervisor and responsible for training. During interview and record review with the Administrator, the SSA’s file still contained no documentation of facility competency or job-specific training. The Administrator stated the facility was without a Social Services Director, that the SSA was the only staff member assigned to Social Services, and that she was providing oversight during the vacancy. The SSA stated he had very limited knowledge of his job duties and responsibilities and that he had not received proper training. The Administrator later stated the SSA had received only verbal training, that no documentation was maintained in the personnel file, and that the facility did not have a formal training plan for the SSA.
Failure to Maintain CNA Training Records
Penalty
Summary
The facility failed to maintain an effective training program for one of three sampled CNAs when it could not provide documented evidence that CNA 3 completed the required continuing education units needed to renew an active certification. During an interview, CNA 3 stated she had completed the 48 hours of CEU required for renewal, but the DSD could not find the in-services. During a concurrent interview and record review, the DON reviewed CNA 3’s training records from January 2024 through December 2024 and stated she was not able to verify some of the training records because CNA 3 either never signed, never attended the training, there was no proof CNA 3 completed it, the person giving the in-service did not write a topic, or CNA 3 did not fill it out properly. The DON stated the current DSD can only verify what she has. During a later interview, the DSD stated the facility is responsible for maintaining the training records and said the facility does not have a specific policy on maintaining in-service trainings, and she was unable to provide one. A review of the DSD job description showed that maintaining records of in-services was listed as an essential duty.
LPN Returned After Narcotics Incident Without Required Education
Penalty
Summary
Facility staff failed to implement an effective training program for existing staff when Employee #6, an LPN involved in a reported incident of missing narcotics, returned to work after suspension without documented education on drug diversion and narcotics reconciliation. A Facility Reported Incident documented a possible narcotics variance, and the follow-up report stated that Employee #6 found an Oxycodone IR 5 mg tablet difficult to remove from the pack, discovered the back of the pack had been tampered with and taped closed with clear tape, and found the Oxycodone tablet had been replaced with Loratadine tablets of similar color, size, and shape. The report also stated that five tablets were missing in total. Review of the employee’s timecard showed she worked the night shift after suspension, and review of education records showed no documented evidence that she had completed or received the required drug diversion/narcotics reconciliation education before returning to work. The DON and Staff Development/Educator acknowledged that the employee should have received the education prior to restarting work after suspension.
Missing Mandated Reporter Training Documentation
Penalty
Summary
The facility failed to ensure that one of one staff member, LVN 7, completed Elder Abuse Mandated Reporter training in accordance with the facility's policy and procedures titled Training Requirements. During a concurrent interview and record review of LVN 7's personnel file, the file did not contain evidence of Elder Abuse Mandated Reporter training upon hire. The Director of Staff Development/LVN 2 stated there was no Elder Abuse Mandated Reporter training in the staff member's file and, after checking the facility's electronic system, was unable to provide any additional information regarding abuse training for LVN 7. During interview, the DON stated that if the abuse training is not in the file, there is no way to verify that the training was completed. The DON further stated that the abuse training provided to new employees should remain in the file to prove they received the training needed to safely perform their duties for residents, and that without it, staff may not know what to do when working with residents. The facility's policy required training on abuse, neglect, and exploitation, including the types of actions that constitute abuse, neglect, exploitation, and misappropriation of resident property, as well as procedures for reporting incidents of abuse, neglect, exploitation, or misappropriation of resident property.
Missing EBP Competency Training for CNA and LVN
Penalty
Summary
The facility failed to ensure that two of three sampled staff members, CNA 3 and LVN 3, received enhanced barrier precautions (EBP) competency training. During a concurrent interview and record review, the Infection Preventionist Nurse was unable to provide documentation showing that either staff member had completed EBP training. During a later review with the Director of Staff Development, the Annual CNA Competency form for CNA 3 and the Initial/Annual License Nurse Competency form for LVN 3 were reviewed, and neither form indicated that EBP training had been completed. The facility’s policy titled Competency of Nursing Staff stated that competency skills include infection control and that competency evaluations are to be conducted upon hire, annually, and as necessary based on assessment. The policy titled Enhanced Standard/Barrier Precautions stated that staff are to receive EBP training upon hire and at least annually. The Infection Preventionist stated she did not have records showing that CNA 3 and LVN 3 completed annual competency assessments and evaluations, and the DON stated the facility was unable to locate documentation of their annual competency assessments and EBP training.
Missing Emergency Preparedness Training for Multiple Staff
Penalty
Summary
The facility failed to ensure that staff members #44, #168, and #182 received training on emergency preparedness. During review of staffing and transcript records on 5/28/2026, the emergency preparedness training was not listed for the Dietary Server, the Physical Therapy Assistant, or the Speech Therapist, and the records did not show when each staff member completed the annual training. The Dietary Server was hired on 12/16/2024, and the transcript history for 2025 did not show emergency preparedness training. The Physical Therapy Assistant was hired on 08/01/2024, and the transcript document did not list emergency preparedness training. The Speech Therapist was hired on 01/05/2026, and her 2026 transcript did not list emergency preparedness training; the transcript also showed other modules started on 03/30/2026, 04/01/2026, 04/22/2026, 04/23/2026, and 05/06/2026. During interviews, the DON stated that staff complete annual training through eCampus and weekly meetings, and that emergency preparedness training is included twice a year. The HRD stated that the facility expected contracted rehabilitation staff to receive the same training as facility staff, but he did not see emergency preparedness training listed for Staff #168 or Staff #182. The facility policy titled Staff Development and Orientation-Resident Care stated that all new and existing staff, volunteers, and contractors would receive training on resident rights, abuse, neglect and exploitation, dementia management, and infection control.
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