Repeated Deficiency in Infection Control and QAPI Implementation
Penalty
Summary
The facility was cited for failing to implement effective Quality Assurance and Performance Improvement (QAPI) activities, specifically in relation to repeated deficiencies under F880, which pertains to infection prevention and control. Surveyors found that the facility did not maintain effective systems to ensure staff adhered to proper infection control procedures, such as changing gloves during care and correctly disposing of sharps and used monitoring supplies. These lapses were identified through observations, interviews, and record reviews during the recertification survey. The report details that the facility's QAPI/QAA committee met monthly and included members such as the Medical Director, Administrator, DON, Preventionist, and other interdisciplinary team members. Despite these meetings and the existence of written policies and procedures intended to guide QAPI activities, the facility failed to correct previously identified quality deficiencies. The repeated citation of F880 indicates that the facility did not successfully implement or sustain corrective actions to address infection control issues. The deficiency was not limited to a single event but reflected a pattern of non-compliance with infection control protocols, as evidenced by staff not changing gloves between resident care tasks and improper disposal of sharps. These failures had the potential to affect all 44 residents residing in the facility at the time of the survey. The report does not provide specific details about individual residents' medical histories or conditions at the time of the deficiency.
Plan Of Correction
F 867 1. On , the QAPI committee met to discuss and re-invent the facility's current QAPI plan that failed to prevent repeated deficiencies related to control practices as staff failed to adhere to proper sharps disposal of used monitoring supplies. Upon discussion, it was determined that failure in the system occurred and intervention to address it would be implemented. During monthly meetings, control and personal privacy audits will be collected for tracking and monitoring. Any adverse findings discovered through monitoring will be addressed among the interdisciplinary team during QAPI gatherings. Department heads will ensure all new processes are implemented in applicable locations. 2. New hire files will be reviewed during the QAPI meeting to ensure educational training on control and residents' rights to privacy/confidentiality is received. 3. The facility QAPI process and current performance improvement plans were reviewed, and revisions needed were made by the Administrator to ensure that no other areas were affected. DON implemented training, education, and a plan of correction expressed in other areas to address failures in the system discussed during the meeting on 4. 4. A performance improvement project was implemented on control practices to include previous survey citations related to control (e.g., monitoring supplies disposal, cleaning vial, PPE usage when performing care). 5. The preventionist and the Director of Nursing were in-serviced by the administrator on the revised QAPI/QA&A policy and procedures. After conducting training, the Administrator observed compliance by each staff member. 6. The administrator re-educated and reminded all department heads of the importance of following the QAPI Policy & Procedures. After conducting training, the Administrator observed compliance by each staff member. 7. The administrator will conduct QAPI audits once a month for the next 3 months. The administrator will track and monitor audits performed to verify systems are working. 8. These audits will be presented to the QA&A committee monthly for recommendations. 9. The committee will determine the need for further auditing beyond the three months if any.