Failure to Document Employee Orientation
Summary
The facility failed to ensure that employees received orientation to the facility and their assigned positions prior to or within one week of their start date. This deficiency was identified through a review of employee personnel records and staff interviews. Specifically, the records for three employees—Dietary Aide Employee E3, Housekeeping Aide Employee E4, and Nurse Aide Employee E5—lacked evidence of the required orientation. Dietary Aide Employee E3 began working on August 27, 2024, Housekeeping Aide Employee E4 on August 1, 2024, and Nurse Aide Employee E5 on October 15, 2024. During an interview on January 8, 2025, the Nursing Home Administrator confirmed the absence of orientation documentation for these employees.
Plan Of Correction
The facility identified a break down in the orientation process effecting non-clinical staff. IDT (Interdisciplinary Team) team has been educated on providing effective, facility-based orientation to all staff upon hire. All staff employed at the building were provided a facility-based orientation to determine they have the proper resources and education. Facility looked back 4 months to identify any staff members that did not receive the adequate orientation to the facility and provided them this information. Moving forward the Nursing Home Administrator (NHA) or designee will audit 50% of new hire files to determine facility-based orientation is being provided. This process will be reviewed in our Quality Assurance Performance Improvement (QAPI) plan and updated as needed based on ongoing audits.
Penalty
The facility did not document that four employees, including Nurse Aides and an RN, received orientation to the facility and their positions within the required timeframe. Personnel files lacked evidence of completed orientation, and the Nursing Home Administrator confirmed this deficiency.
Failure to Document Employee Orientation
Penalty
Summary
The facility failed to ensure that personnel records included evidence of employees receiving orientation to the facility and their assigned positions prior to or within one week of their start date. This deficiency was identified during a review of employee personnel records and staff interviews. Specifically, four out of five personnel files reviewed did not contain documentation of completed orientation for the employees, who were Nurse Aides and a Registered Nurse. The hire dates for these employees were all the same, and as of the review date, their files indicated they were still in orientation. The Nursing Home Administrator confirmed the lack of documentation for the required orientation within the specified timeframe.
Plan Of Correction
All personal files were reviewed for completion. Education will be provided to the educator on timely completion of new hire paperwork. Audits will be completed by HR weekly for 8 weeks, then monthly. All results to be reviewed through QAPI for further recommendation. 2/25/25 All personal files were reviewed by HR to ensure completion of job descriptions with staff signatures. Personal files will be reviewed weekly by HR and the Administrator for 6 weeks, then monthly. All newly hired staff to sign off on their job description during the "hiring process." All results to be reviewed through QAPI for further recommendations.
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