Failure to Implement Effective QAPI Actions for Infection Control Deficiencies
Penalty
Summary
The facility failed to identify, implement, and document effective quality assurance and performance improvement (QAPI) plans to address ongoing infection control deficiencies related to hand hygiene and personal protective equipment (PPE) compliance. Over a three-month period, audits consistently showed that staff compliance with hand hygiene and PPE protocols remained below the facility's established benchmarks. Despite monthly QAPI meetings and the identification of these issues, the only action taken was to continue staff education, with no additional interventions or strategies documented to address the persistent non-compliance. Observations and interviews during the survey period revealed that these deficiencies potentially contributed to an outbreak of gastrointestinal illness affecting multiple residents and staff. QAPI records showed inconsistent benchmarks for compliance and repeated documentation of the same issues and corrective actions across several months, with little to no change in outcomes. Meeting notes often left outcome sections blank or repeated previous entries, indicating a lack of effective follow-up or adjustment to the plan of correction.