Repeated Deficiencies in Physician Orders, Catheter Care, and Nutrition
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations, as evidenced by repeated deficiencies identified in a recent survey. The survey, which concluded on April 16, 2025, highlighted recurring issues that were previously noted in a survey ending May 23, 2024. These issues included failures to follow physician's orders, provide proper care of urinary catheters, and maintain nutrition for residents. The deficiency related to following physician's orders was initially identified in the May 2024 survey. The facility had developed a plan of correction that involved conducting audits and reporting the results to the QAPI committee. However, the recent survey found that the QAPI committee was ineffective in addressing these issues, as the same deficiency was cited again under F684. Similarly, the facility's plan to address deficiencies in catheter care and nutrition maintenance, which also involved audits and QAPI committee reviews, proved ineffective. The recent survey cited the facility under F690 for failing to maintain compliance with catheter care regulations and under F692 for nutrition maintenance. These repeated deficiencies indicate that the QAPI committee's efforts to correct and monitor these issues were insufficient.
Plan Of Correction
The current Quality Assurance Performance Improvement program has been reviewed by the Director of Quality and Compliance. The repeat deficiencies have been reviewed, and audits have been developed to provide accurate data collection and process improvement. The Director of Quality and Compliance will review Quality Assurance and Performance Improvement Minutes. Education has been provided to the Interdisciplinary Team regarding repeat deficiencies. Audits for repeat deficiencies will be completed per their individual plan of corrections. All audits will be reviewed at the Quality Assurance and Performance Improvement Quarterly meeting, where a Root Cause Approach will evaluate new and recurrent deficiencies. Revision or extension of audits will be discussed with the Interdisciplinary Team. Any audits that need to be reviewed will be done at that time.