A competent nursing staff – isn’t that what each Operator, Administrator and Director of Nursing believes that they have working in and providing care to their nursing home’s resident population? In order for that to actually be correct in your nursing home you need to ensure that the nursing staff is knowledgeable, competent and have the required skill set to deliver safe quality care and services to your residents. The nursing staff needs to be culturally competent and understand trauma-informed care. How well prepared are your nursing staff? Do they understand basic concepts such as a licensed nurse’s responsibility for conducting a timely assessment for a change in condition or the nursing assistant being able to demonstrate competent care for a totally dependent resident? We also shouldn’t forget there is usually an assessment of the knowledge and competency of the licensed nurse and/or nurse aide during a state agency investigation let alone whether the Attorney General is involved due to the seriousness of the event. There is an administrative responsibility to ensure that you employ nursing staff who are competent.
Per the definition in State Operations Manual Appendix PP, “competency” is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully.
On Survey: Missing Competencies
F726 S/S: E
A facility was cited at a S/S = E for failing to ensure the nursing staff maintained appropriate skills and competencies to provide nursing care to the facility’s residents. The citation notes that the Director of Nursing provided the surveyors with five (5) forms titled Nurse Annual Competency Checklist with the sampled licensed nurses’ names hand-written on top of each form with a date below. There were no Inservice sign-in sheets for each subject education was provided or skill check for each nursing competency performed, the time of the inservice or education hours credited to the attendee of the inservice was not documented. The Director of Nursing confirmed that each nurse, both RNs and LPNs, had no competencies or evaluations on file. The survey team met with the administrator and Director of Nursing to discuss this concern. No additional information or policy for nursing competencies were provided.
This citation should be a wake-up call to reassess your system for providing staff education, what competencies are needed as well as the need for lesson plans, sign-in sheets with date/time to validate attendance and competency checklists.
The nursing staff’s competency in fulfilling their job duties and responsibilities is fully on display during a recertification survey and these staff members need to be well equipped. Basic care and services that reflect the competency of your nursing staff are on full display when a surveyor is investigating a decline in continence or is assessing how the nursing staff are managing a resident who is displaying behavior symptoms. I always think about how the staff’s heightened anxiety level during a survey translates into heightened behaviors in the resident population and the nursing staff’s behavior is a give-away that they do not have a plan with appropriate interventions to manage the resident.
F726 – Immediate Jeopardy (S/S: J)
An Immediate Jeopardy (IJ) was cited at a S/S = J for licensed nurses not being appropriately trained and deemed competent through an approved and documented validation evaluation related to medication administration. The key finding of this deficiency stems from one licensed nurse, who was new to the facility and assigned the task providing orientation to another nurse, preparing significant medications, including clozapine and two (2) seizure-related medication and giving the medications to an orientee to administer. The orientee administered the medications to the wrong resident as she did not verify the resident’s identification prior to administering the medications. The resident suffered a sudden decline in function with noted altered mental status and was transferred to the Emergency Room for treatment. If that wasn’t enough the citation listed multiple licensed nurses who did not follow the Rights of Medication Administration related to identification of the resident. I think that we can all see the IJ here!
The Regulation
The latest revision of this regulation was issued on 04/25/2025, effective the same date and nursing homes were to have implemented this latest version by 04/28/2025. I hope that you have all taken the time to read this regulation and wrap your head around the contents. The full text and Interpretive Guidance for F726 are in SOM Appendix PP.
Let’s just review the requirements to refresh your memory of what is needed on your part. Remember that all care and services that you provide are geared towards our responsibility to ensure that the resident attains or maintains the highest practicable level of physical, mental and psychosocial well-being. How is this achieved? By accurately completing resident assessments and developing an individualized care plan. Having sufficient nursing staff with appropriate competencies and skills is key to achieving this goal. It is always best practice to provide ongoing education and skills/competency checks of care and services that your nursing staff provided.
The bottom line – don’t admit residents to your facility that your nursing staff does not have the knowledge or competencies to care for. The staff need to be prepared and knowledgeable before a resident enters your door. Your Facility Assessment of the nursing home’s population related to acuity, diagnoses and number of residents should be utilized when determining what is sufficient staff and what competencies are needed.
The regulation clearly states that providing care is “not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident’s needs.” This is an all-encompassing concept and reflects the premise of the regulation that you need sufficient as well as competent nurses and nurse aides to address all of these components of care and services.
Licensed Nurses and High-Risk Care
The first citation, cited at a scope and severity of E, related to a facility’s failure to ensure licensed nurses, including nurse leaders, possessed the competencies and skill sets needed to provide care and oversight for residents requiring specialized clinical services and safe medication practices.Concerns were identified related to respiratory/tracheostomy care, which is always a high-risk area. You know it is an area going to be assessed during survey so make sure your staff educator or competent staff are conducting periodic competency assessments of your licensed nurses providing respiratory care. The Director of Nursing was also included in the citation due to their failure to investigate a serious medication-related incident, ensure that the physician was notified of a narcotic discrepancy per policy, and did not implement or maintain disciplinary action for unsafe nursing practice.
In Part 2, we’ll turn to the nurse aides: what the regulation expects of them and what surveyors have cited when their competencies couldn’t be shown.
