|Survey Date: 7/31/2007|
Regulation Title: CEO: STAFF TRAINING
Regulation Description: The responsibilities of the chief executive officer include but are not limited to ensuring that the facility employs the number of qualified personnel needed; that all employees have appropriate orientation to the facility and their work responsibilities upon employment; and that they have an opportunity for continuing education and related development activities.
Based on record review and staff interview, the chief executive officer failed to ensure the facility offered the staff an opportunity for continuing education programs in 6 of 6 personnel records reviewed. The findings were:
The personnel records were reviewed on 7/31/07 and included the registered dietitian, social worker, charge/peritoneal dialysis registered nurse, director of nursing and two patient care technicians.
The registered dietitian was hired in 8/05 and had not completed any continuing education.
The social worker was hired in 6/99 and the last continuing education was completed in 5/11/05.
The charge/peritoneal dialysis registered nurse was hired in 6/00 and the last continuing education was completed in 3/4/05.
The director of nursing was hired in 3/98 and the last continuing education was completed in 3/4/05.
The first patient care technician was hired in 6/1/99 and the last continuing education was completed on 4/27/05.
The second patient care technician was hired in 12/13/05 and that was the last time the technician had education.
The director of nursing (DON) and the medical director were interviewed on 7/31/07 at approximately 11:30 a.m. The medical director stated he was aware of the lack of continuing education with the personnel. However, the director further stated he would be offering education as soon as possible.
In summary, the failure to provide the opportunity for continuing education for facility staff created the potential for adverse patient outcomes.
Facility Plan of Correction:
CEU's were completed and placed into the proper employee files.
The registered dietitian has completed the following continuing education activites: 7/26/07 Optimizing the Treatment Hyperphosphatemia, 5/3/07 earned 1.0 CUE for Vascular Calcification in the CKD patient, 4/13/07 participated in the 2007 in CDA Annual Meeting and Exhibition State conference, 6/14-15/07 participated in Lillian Fountai Smith conference for Nutrition Educations for 10 CPE.
The social worker has completed 1.0 CEU on Herioin: Abuse and Addiction on 8/20/07.
The Charge/peritioneal nurse completed 2/18/07 attended the 27th Annual Dialysis Conference and obtained 18 CEUs. She attended 10/12/06 Conflict Management and Confrontation workshop for .6 CEU. Attended Fundamentals of Peritoneal Dialysis on 5/22/06 for 4.5 CEUs.
The DON completed Conflict Management and Confrontation workshop for 0.6 CEU on 10/12/06, completed online water treatment sessions 100, 200, 300, and 305 on 10/17/06,earned 1.2 CEUs for The Continued Importance of Preserving Logn-term Reanl Funcion Posttransplantation on 1/5/06.
Tech #1 completed online water treatment for dialysis sessions 100, 202, 203, 204, 205, 206, 301, and 305 on 10/17-19/06.
Tech #2 completed online water treatment for dialysis sessions 100, 202, 203, 204, 205, 206, 301, and 305 on 10/17-19/06.
To ensure that continuing education is being completed, a quarterly review of employee files will be completed by the DON. She will note the results on a checklist that will be placed in the QA manual.