QAPI Program Fails to Address Repeat Deficiencies in Environment, Kitchen, and Infection Control
Penalty
Summary
The facility failed to ensure its Quality Assurance Performance Improvement (QAPI) program effectively identified and addressed concerns related to deficient practices found during the annual survey, as well as repeat deficiencies from previous surveys. Specifically, the QAPI program did not maintain correction for issues such as environmental cleanliness and maintenance (F 584), dental appointment follow-up (F 791), kitchen sanitation (F 812), and infection control practices (F 880). The QAPI committee was responsible for reviewing survey results, internal audits, infection control data, grievances, accidents, clinical outcomes, dietary performance, and performance improvement plans (PIPs), but failed to implement effective interventions for recurring issues. The facility's policy required regular meetings and data-driven interventions, but these were not successful in preventing repeat citations. During the most recent survey, deficiencies included failure to protect residents' property and maintain cleanliness in resident rooms, lack of follow-up on dental appointments, inadequate maintenance of kitchen appliances and floors, and improper infection control practices such as not disinfecting glucometers between uses and improper handling of catheter bags. These deficiencies had the potential to affect all 69 residents in the facility. Interviews confirmed that environmental and kitchen sanitation issues had been cited in previous years, and while a PIP was initiated for the kitchen, it was not effective in maintaining correction, and no PIP was implemented for environmental concerns.