Based on observation, interview, and record review, during a site visit conducted on 01/02/24, it was confirmed the facility had not documented they have observed and evaluated an individual's ability to perform safe medication and treatment administration unsupervised. Findings include, but are not limited to:

During swing shift on 01/02/24, CS observed Staff 5 working alone.

During separate interviews on 01/02/24, Staff 2 (RN) indicated new med techs were trained for two weeks with another med tech who had been fully trained. S/he indicated that there were check ins with new staff to ensure they were comfortable with their position and if there was additional training needed. Staff also complete a 30-day competency checklist which was observed and signed off by a trainer. Staff 4 (MT) indicated Staff 5 was a new MT that would be working the swing shift passing medications alone.  

A review of MT training records indicated four out of six med techs to have been completed. Staff 5 competency training had been incomplete and had not been signed off by a supervisor.

it was confirmed the facility had not documented they have observed and evaluated an individual's ability to perform safe medication and treatment administration unsupervised.

On 01/02/24, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: ED stated that the facility would complete and sign off MT competency.