HospitalInspections.org

Based on staff interview and review of facility documents including the credible evidence from the plan of correction for the previous survey, the facility staff failed to ensure the plan of correction was fully implemented related to staff education.

The findings included:

During a review of the facility credible evidence and clinical records, it was evidenced that not all employees had attended the required in-servicing as stated in the plan of correction.

The facility's plan of correction (POC ) included implementation of a new wound care policy to include the Braden scale and wound care education. The POC stated that the "DON (director of nursing)/designee was to provide the education/ in-service, and maintain an in-service log "for in-services on the new wound care policy, wound care education, and the Braden Scale. During a discussion regarding the facility's wound care related in-services on 6/16/2015 at approximately 12:00 PM, Staff Person #1 stated that they were "to include all licensed staff, and that the in-services were mandatory". The surveyor, upon request, was given a list of 21 (twenty-one) licensed RN's (registered nurses) and 4 (four) LPN's (licensed practical nurses) who were required by the facility to attend the sponsored mandatory inservices related to the new wound care policy as outlined in the facility's plan of correction.

The surveyor noted that the sign in sheet for the required Braden Scale in-service lacked documentation of attendance for 5 (five) licensed staff. The date range that staff signed the in-service sign in sheet was between 4/25/2015 and 6/5/2015.

The surveyor noted that the sign in sheet for the required wound care policy in-service lacked documentation of attendance for 6 (six) licensed staff. The date range that staff signed the in-service sign in sheet was between 4/21/2015 and 6/8/2015.

The sign in sheet for the required wound care in-service lacked documentation of attendance for 7 (seven) licensed staff. The date range that staff signed the in-service sign in sheet was between 4/06/2015 and 6/8/2015.

The surveyor discussed the lack of documentation that all required staff attended the facility's mandatory in-services related to the new wound care policy with Staff #3 on 6/16/2015 between approximately 11:00 AM and 12:30 PM. The MFI asked for any further documentation of in-service attendance; however, none was provided prior to the end of the survey.

The lack of documentation that all required staff had been in-serviced as stated in the facility's POC was discussed with Staff Persons 1, 2, 3, and 7 on 6/16/2015 at 1:30 PM at the time of the exit conference.