Repeat Deficiencies in Pressure Injury Care and Infection Control Due to Ineffective QAPI Implementation
Penalty
Summary
The facility failed to develop and implement effective approaches to maintain a Quality Assurance and Performance Improvement (QAPI) program, resulting in repeat deficiencies related to pressure injury care and infection prevention. During the last annual recertification and state licensure survey, the facility did not provide adequate monitoring of a pressure injury and did not implement interventions to promote healing. Additionally, the facility failed to utilize infection prevention and control strategies to prevent contamination of wounds during wound care. These deficiencies were again cited in a subsequent survey, where it was observed that interventions to promote healing and infection control strategies were not implemented for residents with pressure injuries. Interviews with facility leadership revealed that QAPI meetings were held at least quarterly, sometimes monthly, and covered previously identified areas of concern. However, the Director of Nursing (DON) was unable to provide documentation supporting the initiation of a Performance Improvement Plan (PIP) related to pressure ulcers after the previous survey. The facility's QAPI policy outlined a proactive approach to quality improvement, but the lack of implementation and documentation contributed to the recurrence of deficiencies in pressure injury management and infection control.