Failure to Implement Effective QAPI Response to Scabies Outbreaks
Penalty
Summary
The facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) program as required, specifically in response to two documented scabies outbreaks. The QAPI committee did not develop, implement, or identify performance improvement activities related to these outbreaks. Review of the facility's QAPI policy indicated a requirement for ongoing, data-driven quality management, but records showed that outbreak tracking tools were incomplete, with missing information on specimen collection, lab results, prescribed treatments, recovery dates, and resident status for affected individuals. Additionally, documentation of medical director notification was inconsistent or lacked specific dates. Meeting minutes from infection control and QAPI meetings revealed insufficient documentation and follow-through regarding the scabies outbreaks. While some references to skin issues and in-service education were noted, there was a lack of detailed tracking, trending, or evaluation of corrective actions. In particular, the July meeting minutes did not include any mention of the scabies outbreak or related performance improvement actions, and there were no QAPI minutes available for a three-month period during which the outbreaks occurred. Interviews with facility leadership, including the DON, Infection Preventionist, and Administrator, confirmed that documentation was lacking in terms of tracking, trending, and evaluating the facility's response to the scabies outbreaks. The absence of comprehensive records and performance improvement activities resulted in 31 residents, as well as all staff, vendors, and visitors, being at risk for exposure to scabies.