Failure to Sustain Effective QA&A Program for ADLs, Falls, Care Conferences, and Admissions
Penalty
Summary
The facility failed to implement an effective Quality Assessment and Assurance (QA&A) program to ensure that corrective actions for identified problem areas were monitored and sustained. The QAPI Committee was responsible for analyzing data, establishing benchmarks, and monitoring performance improvement plans (PIPs), but repeated deficiencies were found in several areas, including activities of daily living (ADLs), falls/monitoring, care planning conferences, and admission procedures. These deficiencies were identified during a recertification survey and had also been cited in previous complaint and recertification surveys. In the area of ADLs, multiple residents with chronic health conditions and physical limitations did not consistently receive the required assistance with showers, oral care, and nail care as documented in their care plans. For example, one resident with COPD, seizures, and chronic pain did not receive two showers per week on several occasions, and another resident with similar needs also missed scheduled showers. A third resident, dependent on staff for oral and nail care, was repeatedly observed with foul-smelling breath and dirty fingernails, indicating a lack of daily oral care and nail hygiene. Staff interviews confirmed that care was not provided as scheduled, and documentation was inconsistent with actual care delivered. Deficiencies were also found in falls monitoring, care conferences, and admission processes. The facility did not consistently monitor residents after falls, and the reduction in falls was not sustained or fully analyzed. Care conferences were not consistently offered or held, with only one out of twelve scheduled conferences completed in a given period. Admission documentation was not completed as required, and the monitoring of corrective actions in this area was not sustained. Staff interviews revealed a lack of awareness and follow-through regarding these ongoing issues.