QAA Committee Lacked Required Infection Preventionist Participation, Leading to Norovirus Outbreak
Penalty
Summary
The facility failed to maintain a Quality Assessment and Assurance (QAA) committee that met at least quarterly with all required members, specifically omitting the Infection Preventionist from participation. Review of QAPI committee meeting minutes over four consecutive quarters showed no documentation of attendance or input from the Infection Preventionist, and no infection prevention and control data was presented. The Infection Preventionist confirmed in an interview that they had not participated in any QAPI meetings, were not monitoring infection control practices for trends, and had not initiated any infection control Performance Improvement Projects. As a result of these lapses, the facility's interdisciplinary QAA team was unable to effectively identify and address processes and outcomes related to infection control practices and disease management. This deficiency coincided with a Norovirus outbreak, during which 27 of 61 residents and 33 staff members contracted the highly contagious gastrointestinal illness, as documented in the facility's GI outbreak line listing.