QAPI Program Fails to Correct Elastic Bandage Deficiencies
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) program failed to address previously cited deficiencies related to the improper use of elastic bandages, affecting 16 of 140 residents. A review of the facility's documentation and staff interviews revealed that the QAPI program did not effectively correct the issues identified in a prior survey conducted on 3/22/24. The plan of correction from the previous survey included audits and education for staff on the proper application of compression stockings, ted hose, and ACE wraps. However, during the current survey ending on 12/19/24, repeated deficiencies were identified, indicating that the corrective measures were not successfully implemented. The survey findings showed that five out of ten residents had issues with the application or absence of ACE wraps. Specifically, two residents had their ACE wraps applied incorrectly, with the wraps being reversed from the knees to the toes. Three other residents did not have ACE wraps on at all. During an interview, the Nursing Home Administrator and the Director of Nursing confirmed the facility's failure to maintain an effective Quality Assurance Committee to address these concerns, which had the potential to affect 16 residents.
Plan Of Correction
After notation, the facility conducted a QAPI meeting to review the facility policy regarding the Quality Assurance and Performance Improvement program. All residents with compression stockings, ted hose, and ace wraps will be identified monthly during QAPI to ensure proper monitoring. The Director of Nursing/designee will observe nurses apply/remove compression stockings and report findings to the administrator. The Director of Nursing/Designee will monitor residents ordered compression stockings, ted hose, and ace wraps for proper application and removal daily. The Director of Nursing/designee will report findings to the administrator monthly at the QAPI meeting. To prevent future occurrences from happening, the Administrator will educate the Director of Nursing to ensure that those identified with an order for compression stockings, ted hose, and ACE wraps are being reviewed monthly during QAPI. The Director of Nursing/designee will educate all nursing staff on following orders as it relates to compression stockings, ted hose, and ace wraps. The Administrator/designee will complete an initial whole house audit, then weekly audit x 4 weeks, then monthly audit of all residents with compression stockings, ted hose, and Ace wrap orders. Then monthly thereafter with reporting through the Quality Assurance and Process Improvement Committee for review and/or recommendation ongoing.